HomeMy WebLinkAboutSeptic Pumping Slip - 163 OLYMPIC LANE 6/9/2016 Commonwealth of Massachusetts
City/Town MAY "2p 1 2008
System Pumping Record
Form
DEP has provided this form for use by kcal Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the farm they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: tea)
forms on the �j (�. me
computer, use
only the tab key Address
to move your �Jl a✓ 1�. `t
cursor-do not
use the return City/Town State Zip Cade
key. 2. System Owner:
Name —
Address(if different from location)
City/Town State Zi ode
Telephone Number
B. Pumping n Record
1. Date of Pumping bate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) E7 Septic Tank ❑ Tight Tank
❑ Other(describe):
,i
4. Effluent Tee Filter present? [:1 Yes o If yes, was it cleaned? ❑ Yes ❑ Na
5, Condition of System:
V �..
6. System
Name '"5 /Vehicle License Number
Company
7. Location re c ntentTwere d' ed:
e .
Signature ler hate
t5form4.doc•06103 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts ..
City/Fown of I
System u pin rd kl, 215 h611 vw
Farm 4 I
DEP has provided this form for use by local Boards of Health. The `Ystem"PuTirip ift 'Rd 6fd must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling out 1. Syst m Location:
forms on the �
computer, use .4... ......,_ t.. - ',��...
to only the tab key Address . —�. - - F- W
� Gc
cu sordo not
use the;return City/Town "� State Zip Code
key. 2, System Owner;
Name - — - - - --
Address(i(different fram location) ---
----- ----------
City/Town Stat
--------- -- ----
Zip Code
Telephone Number
13. Pumpirig .Record
1. Date of Pumping Date 2. Quantity Pumped: — - --
Gallons
3. Type of system: ❑ Cesspool(s) e'pfic" Tank- ❑ Tight Tank
❑ Other(describe): ---- -- --- -------
4. Effluent Tee Filter present? ❑ Yes ❑.AD If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
6. S st ,m Punt ed By-.
y wp
Name Vehicle License Number
- --
a �
Company ---
1 ti re disposed;
7, Locat ow
rr w e re cant nts
Sj nat "e Hauler - pate — -
http://www.mass.gov/dep wa er/approvals/t5forms.htm#inspect
t5form4.doc^06103 System'Pumping Record•Page 1 of 1
F�
f
A
TOWN OF
SYSTEM PU PING
IDATE.
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
r
(example: left front of Douse)
IDATE OF P ING: :_. QUANTITY TITY PU EID : GALLONS
CESSPOOL: NO YES SE PTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE 12 EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES I PLACE
ROOTS LEACI + ELID RUNBACK
EX CE SSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM M PUMPE ID BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONTENTS srE, D TO: G.L.S.D Lowell Waste
Commonwealth of Massachusetts
Massachusetts
System Owner System Location
Date of Pumping: Quantity Pumped: gallons
Cesspool: No4-]--' Yes [] Septic Tank: No Yes [-T—"
Pumped by: Vdmuw saao4a" License#
is transferred to: Greater Lawrence Sanitary District
Inspector:
Ccror monwvealill ofmass"Clitwsells
_�
Sysl��u �)�vr�er Cr.,..., _ ... t.juai►lily I'��tralrecl: �w"�� t�IlaNrs
I)HIC of Irllllllrillg:
Cesspool: Jr ves se lic 'I'tlulc: PJr H-0
Sysietil Pumped by: Fare4we 4o"iaej License #
colliellis li ansfer rrec!
Dole: lns recicrl: -- -.__------ ___�.