HomeMy WebLinkAboutSeptic Pumping Slip - 136 RALEIGH TAVERN LANE 7/8/2016 Commonwealth of Massachusetts
City/Town of
Y° System Pumping Record
Form 4
DEP has provided this form 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 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/Right front of hous ear house Left/right side of house, Left/
Right side of building, Left/Right front of rgh r ear of building, Under deck
Address �
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown Stat
. 773 7 '9C? '�1--'
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 9__No If yes, was it cleaned? ❑ Yes ❑ No
" 5. Condition
cs
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo 7)e contents were disposed:
GL.. Lowell Waste Water
aA
Sign t Date
t6form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Maschin tt
iffy own of 01
Sys' tem Pumping Record
Form
DEP has provided this form 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 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/Right front of hour , LeL'nigh ear of hour. Left/right side of house, Left/
Right side of building, Left/ Right front of building, Left/Righ er at r obuilding, Under deck
Address
Cityrrown State Zip Cade
2. System Owner: 0 2 2015
Name
Address(if different from location)
City/Town St��y Zip
Telephone Number
B. Pumping Record
Qf 0 L .,.r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 1 Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No.
5. Conditi n f System:
( .
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
C.
SignAtuTe qt HaulerU Date
t5form4.doc•06103 System Pumping Record.Page 1 of 1
Commonwealth Ith Of Massachusetts
City/Town Of
System Pumping c rd
a, Fo1'fn 4
Pr '� lh�ill 1`hx ➢�/f �JR
DEP has provided this form for use by local Boards of Health. Other forms may be used, t"t mM
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/Right front of house /Nigh rear of housLeft/right side of house, Left/
Right side of building, Left/Right front of bul ing, Left/Rig°fif rear of building, Under deck
Address
City/Town U State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zi C
&,I
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. 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:
_
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ere contents were disposed:
L S, Lowell Waste Water
Sign to a Haule Date
t5form4.doc•06/03 System Pumping Record a Page 1 of 1
Commonwealth of Massachusetts
U ity/Town of ��u � � �� too
wuoa wwiW
u
System u 6n Record
Form 4 (5 EP k '' Z dui
information must behsubstaryt for
the same as that pro
p Y 1661K.4013
3 used, but the
1 01
a s 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
rear of house„ fight rear of house, left side of building, right rear of building, under deck, eft
stem Location: Left front of house right front of house left side of house right side of house L„
,.....
City/Town State Zip Code
2. System Owner: µ )
Name a. —
Address(if different from location)
City/Town Stat .. �. - Zp,.Code m C
Telephone Number
B. Pumping Record
1. Date of Pumping Date — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑"-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a"4o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of
stem:
6. System Pumped By:
Neil J. Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location,where contents were disposed:
4reH ell Wa e ter
Date
t5form4.doc<06/03 System Pumping Record•Page 1 of 1
IJ
Commonwealth of Massachusetts
ityfTow n of �� ❑1
a System Pumping Record
Farm 4
OF N ON't.I„f ANDOVER
DEP has provided this form for use by local Boards of Health. Other form r1
T
information must be substantially the same as that provided here. Before t rm, c ec" c 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 of other approving authority.
A. Facility Information
1. em Lo ation:Left side of house, Right side of house, Left front of house, Right front of house,
rear of n
Lff �.. . N hou ; Right rear of house. Left rear of building. Right rear of building.
Address /
City/Town ❑ State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Staff �m Zip Co�
<; t �
Telephone Number
B. Pumping ecord
1. Date of Pumping t 2. Quantity Pumped: — --- —
Gallons
3. Type of system: ❑ Cesspool(s) ❑ peptic Tank ❑ Tight Tank
❑ Other(describe): — - -
'11
4. Effluent Tee Filter present? F-1 Yes �No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi n of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company --- -- —
7. Loco . r where contents were disposed:
— - -- -- —
G.L.
S.d _ Law II ste Wat Signature of a Date — - -- -- — —
t5form4.doc•06/03 System Pumping Record^Page 1 of 1
Commonwealth Ith of Massachusetts
City/Town of
a Pumping Record
v,
Form 4 �;;" r,_ � �.rK r.���,�,,✓I ��
DEP has provided this form 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 form, check with ou
local Board of Health to determine the form they use. The System Pumping Record must be submitte o
the local Board of Health or other approving authority.
A. Facility Information
1. y _ _�lon: Left side of house, Right side of house, Left front of house, Right front of house,
u
Celt rearµ�acawt ,•se, ht rear of house. Left rear of building. Right rear of building.
s em
of h
--
Address C c
City/Town State Zip Code
2. System Owner: --
Name -- — - -
- -- - - -- -- - ------ --------- - --
Address(if different from location)
City[Town State Zi Code-,
Telephone Number
B. Pumping Record
1. Date of Pumping Date - . Quantity Pumped: Canons
3. Type of system: ❑ Cesspool(s) ❑"°S p Tank ❑ Tight Tank
❑ Other(describe): -- -- -
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System"
w
- ------- -- ---
6. System Pumped By:
Neil Bateson _ F5821 _
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. G ca Ion tere contents were disposed:
L.S
Lowell Waste Water
Signature of Hauler Date
t5form4.doc^06/03 System Pumping Record-Page 1 of 1
4 Commonwealth of Massachusetts
City/Town of
I System Pumping Record jU[ rl) 1111] 1'4J0?
Fork 4
I
C
j ,
I�FP has provided this form for use by local Boards of Health. Other forr r>, n y be usw;-,�Utlt °--
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
When filling out 1. System Location'
farms on the
computer, use _ "'"
.,-.
only the tab key Address V
to move your � :�a��;� � .. • �^ '„��� ���` ,.��,.. �.� „°� � �� '� .�
cursor-do not City/Town - — x State r- Cp ode
use the return
key. 2. System Owner:
------------------ - ---- -- - -
Name
Address(if different from location)
Code —
City/Town State
Telephone Number
B. Pumping cord
P .„ „ .., ✓�
1. Gate of Pumping date 2. Quantity Pumped: Gallons
3. Type of system: ® Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes, 0 Jo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System ump 3d By: ._ w
— — — -
Name Vehicle License Number
4 ”
Company
7. Location e contents were dis camas d:
Signa Crate
t5form4.doc-06/03 System Purnping Record m Page 1 of 1
TOWN OF
SYSTEM PUMPING RE CORD
DATE: C f5
SYSTEM OWNER ADDRESS SYSTEM LOCATION
(example: loft front of house)
vk
VS..
LDA'T'E OF PU ING: 0 ).- °� QUANTITY PUMPE TD : 0 )D GALLONS
CESSPOOL,: NO YES SEPTIC 'I C: NO YES
-7 NA'T'URE OF SERVICE: ROUTINE, EMERGENCY
OBSERVATIONS:
GOLD CONDITI®N FULL L TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIE LLD RUNBACK
EXCESSIVE SOLIDS FLOODED
DELD
SOLIDS CARRYOVE R OTHER (EX LAIN)
COMMENTS:
NTS:
CONTE,NTS TRANSFERRED TO: .L. . L well rite
F
J/
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
N.
DATE OF PUMPING: ----"UANTITY PUMPED � � °°�" GALLONS
CESSPOOL: NO
S SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ..EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: `"
Coco moll wreal(ll of,Massachusetts
A.e) ,
Massachusetts
fjy
Atem glum ii Record
System Omieer System t-,canon
Date of t'ittrtping: ( uaittity Pumped:
Cesspool: N � ves H Septic lank: No I_] Yes '[-T .._
System t'umped by: velredare License#
Conteiits transicrrred (o : Ur.eater gwiregr Apr It a l trieQ__
Date: -__—_-- --- ltrspector'
Commonwealth cif Massachusetts
Massachusetts
in ReP r
System Owner System Location ____
(C) l 1� �� �, \ Ve.r.
Date of Pumping_��_w����"� Quantity Pumped:��
CMBV -1: No Ivlf Yes I Q—TLw : No ❑ Yes I�
System Pumped by: License
Contents transferrred to : qre to l..ewrence Sanity District
Date: _�_� Inspector:
L`ORNI 4 n SYS' T,.N1 PU.NIPLNG RECORD
Tt."t Off' & I P i
Conunonwealth of Massachusetts �,�� ��u�m��"j. �L,A' K��
Massachusetts
,Sy_stem1PPujWLng Record
stem wrier ystem _.oeation
6 CIN
Date of Pumping: ` "°" Quantity Pumped: & rw gallons
��W�"�"�,
Cesspool: ?ti o Yes Septic Tank: No El Yes
System Pumped by. .._ License
Contents transferred to;
Date Inspector