HomeMy WebLinkAboutSeptic Pumping Slip - 83 LOST POND LANE 7/7/2016 1
Cornmonwealth of Massachusefts
City/Town oi
p System Pumping Record
•
y
p Form 4
DEP has provided this farm for use by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this farm, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Faclifty, Information
1. System Location: Left i ht front of hour ` Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Righ rant of building, Left/Fight rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
[4rca-�cxA.
Name
Address(if different frctn lotion)
a
Citylrown 1 State V t dip
Telephone Plumber
B. Pumping Record
1. Date of Pumping date 2. Quantity Pumped:
Gallons
3. Type of system: El Cesspool(s) Septic Tank [I fight Tank
El Other(describe):
4. Effluent Tee Filter present? Yep o If yes was it cleaned
- ® Yes Ej Na.
5. Condition of Sys em: 4,
6. System Pumped By:
Neil Satesbn F5821
IVarne Vehicle License Plumber
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
ISIgn Lowell Waste Water
e Houle
�-ba
t5form4.doc-06103 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts
City/Town Of
System unpin Record
a, rrrr�
a a
Form 4
DEP has provided this form for use by local Boards of Health. Othe r farms 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 form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of ho e, front Right M _h
ryw of house,
Left rear of house, Right rear of house. _.___,. _
Address
_? _, a 1a
City/Town State Zip Code
2. System Owner: -
Name —
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ecor
1. Date of Pumping Quantity Pumped: ..
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: e,
6. System Pumped By:
Neil Bateson
Name Vehicle License Number F5821
Bateson Enterprises Inc
Company
7. Locafian where contents were disposed:
�gLl(.. ) Lowell Waste Water
Sin of Hau l r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
N. City/Town of
System u pig Record
Form
DEP has provided this form for use by local Boards of Health. Other fo s-m be,used, but
information must be substantially the same as that provided here. Before using this foram,check with your
local Board of Health to determine the form the y 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, � ° ��.
�� `
forms on the J"'
computer, use _A�., 4
only the tab key Address (,,.. l -
to move your �.
cursor-do net - - — ----------------- —at
- ---- -----------
use the return City/Town State Zip Cade
key. 2. System Owner:
r�
---------------- ------
Name
—----- ------ ----- ---- -- --- -----
Address(if different from location)
City/Town State o ( y - V Zip Cade
Telephone Number
B. Pumping c®r
1. Date of Pumping Cate 2. Quantity Pumped: Gallons - —
3. Type of system: ❑ Cesspool(s) ❑ "peptic Tank ❑ Tight Tank
❑ Other(describe): — --
4. Effluent Tee Filter present? ❑ Yes ❑"No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition o System /
l
w. ^
6. Syste P U nped By: ,,...
�..,
Name .,� Vehicle License Number
Company
7. Location re contents w disposed:
Signatwf a oPH ler date --
t5form4.doc^06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of I �
V 1
System u pi n rd
�
� 7
Form 4 �
DEP has provided this form for use by local Boards-of health. he ystem�p6mpin4Re ord must
be submitted to the local Board of Health or other approving a th6eity. .
A. Facility Information ------
Important:
computer,use Cn Location:
forms on the �`
cq
When fillip out Ste oca
g Y �
Y the y Y - --
cursoVedobnot
Address _r ,,, - — v A - I,,/
use th&return City/Town State Zip Code
--
key. 2. System Owner:
Name - - - - -----
etr° Address(if different from location)
— -- ---
Cityffown State y �� Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping date — 2. Quantity Pumped; Gallons -
3. Type of system: ❑ cesspool(s) ❑ eptic Tank ❑ Tight Tank
❑ Other(describe): - -
--------------
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S stem:
VtA-ex'C'
6. System Pu peg By ,
Name Vehicle License Number
Company
.7. Locatio here contents were d` osed:
Signatu of aule, Date - —
http://www.mass.gov/dep ater/approval8/t5forms.htm#inspect
t5form4.doc^06103 System'.Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: .W,, 1 %
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
r (example: left front of house)
(
DATE OF PUMPING: � J QUANTITY PUMPED �^� � GALLONS
CESSPOOL: NO - " "YIJ
S SI✓PTIC TANK: NO YES
NATU RE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONIDITION FULL TO COVE
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
Commonwea th of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
Date of Pumping: Quantity Pumped: /,. ifions
Cesspool: No [� � Yes [] .Septic Tank: No [] Yes
System Pumped by: 64&44W 5a&v4&W License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
"ommonwealtlr of Massachusetts
Massachusetts
_.19y-gto M -I _ 9 --. ,v
System Owirer System Location
Date of 11nmpin,g: � � Qrrairtity Pumped: � gallons
Cesspool: No Yes (.. ) Septic Tank: No Yes
System Pumped by arejer6 5,re&mjWJeJ License #
Contents transfierrred to : Gr�trtrrr lawrrrsr�re ��rtiltary Iiatrtct _
Date: _ �___�____ __ Inspector: