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Home My WebLink AboutSeptic Pumping Slip - 83 SHERWOOD DRIVE 7/21/2016 Commonwealth of Massachusetts City/Town of System Pumping Record ` Form 4 in provided must this forml a tially the samelas that provided here. Before using this form #fie information , 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 Right side of bui'Left/ Right front h_ofs?7 Left/Right rear of house, Left/right side of house, Left/ System rf` Right- ou Idt building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State _ ..Zip Code G 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 resent? ° f p E] Yes If yes, was it cleaned? E] Yes ❑ No 5. Condit i n System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location-w ere contents were disposed: G.L S. Lowell Waste Water k7-- 1, Sign toe I HaulerU Date t5form4.doc•06/03 System Pumping Record>Page 1 of 1 Commonwealth Of Massachusetts w City/Town Of � « System Pumping c r Farm 4 V'ih Sy`e�� W t 1\Bqt)OVER DEP has provided this form for use b local Boards of Health. Ot r f �' � C ,btt the use,p Y ► is inky i ° 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: Lt side of house, Right of l lght front of house, Left r r of house, Right ear of house. Left side building. Right reap buiding. Address d' City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State „. 4ip God Telephone Number B. Pumping Record 1. Date of Pumping pate 2. Quantity Pumped: Canons 3. Type of system: ❑ Cesspool(s) ❑""Sep Tank ❑ Tight Tank ❑ Other(describe): -- 4. Effluent Tee Filter resent? . ......a.. p ❑ Yes If yes, was it cleaned? F-1 Yes ❑ Na 5. Condition of,System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L Lowell Waste Water 70 g to a of Haul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 rl, {, 1' �'" �f '4 '1' Y"r,'f ldl t ,hi" v.•yyr, W Ilr .(�'• L r' ral;Orr (1 ,y vvC1 Y 1 i,.I(tllr;l%Y'iv s, A u 1 11, C P.ha� prdJlded tht form for use by local hoards of Health, The System Pumping Record mus! be submlpr to the.local Board of Health or other approving authority, A. Facility lnfor tion — , Wt1an(along out 9, System Lecca lion b COWU only the tab key Address V 111 to move your. do not CI the rotum ty/Town Slate 4tv r; r A I, 7jp Code System Owner y �'�,' t' Addra•as(I(dlHerent from,locatlon) y CIV'rown , Slate 7J — a �°'� C Telephone Number -- '!��ti �` If lfir�ft �'=II+�"}r(. 'tr'(11 v9t�l��IlYrlf'�j.lt �� r• � + 1 Pumping 2, Qu Dole a ntlry d; °' Pumped: Gallons — :Typ® Pf system ❑ Cesspool($) Septic Tank ❑ Tight Tank 'rOther(desorlb 4 Efifluent Tee Filter` resent? Yes N y P ❑ o It yes, was It cleaned? c' ❑ Yes ❑ No `a Con ►t1on 01 8 m tr .. _ ,. , ✓ti 4. rt" t,.r,w,;•.f�r,h Ir�d r"a � ., ,Iry l+y •' r�,t ��+,� {",q(7 Jl'l�.rAl�J, `711a1C t'I„ 1.1�y:t ��, Yt 1 F �^Yla, „•),,r,�t�Y jri Y"• Y �•'r�J j, ' w _ AY-I", Sy Pumped By:- r4 tva. '-Y r,J ama.f�'ti;.;��i't;,µ, +a,} ,lo•. _ VOlde UC,0 to Numbe np 4 r Y,x r 1{�yt :.y.;� ,,,, , r,,,i",,�.,•i 10,+%�,t,,�r' r,+w..t�f; (y� r°�K�Y.,rlil ll,,,, LocatlQh where'Cont®nts yvi ra'di posed, ,� Y ,i`{r I f 1i hrr b �,;,,.+.�I t.•'�'il'N� , � m. �.. ,,;: y >•,.,,,;�'"` '>+�:';;: Delo http�/wtivw mass,gov%deb%velar/approva�s/t5fom�s,htm#(nspect t6tom docy 06/03 System Pumping Record Page ct 1 r.r z>ar aM•..3�w•;"� s �`� �;;JI "}rM,{},y� �°'*" k�'+�Cr!f'�'t 4�d ,,'+at Yc�pf? 4h d� r}r1"�. a i ✓u� � ar a }J;r ��b,r� r 4r�aJt 1,�71��rd i tr •�� ✓ m ty ) 'vw1 �r y N A W� N t OfflHA X #Y� .:,1 , s. ,j ��!r "fix; r{ s r IP 4 a' w � G ,• .. �y p� ,1,gy J t car i p 1 1 x !111 9 • — .{. P6�JI D_ � ,. ,,.,._ ,mom, EP has'provtded this form for use b local Boards of Wealth. The System Pumping Record must be submitted to the.local Board of Wealth or other approving authority, Facility Inforniation trr,Portent: fons on the t System Locatlon hen filUn ou computer,use. only the tab key Address tomove our"" � y ✓ °' A,. cursor.do not use^the return Cityfrown k Skate Zip Coda key ! 2 system owner, tit T r rf r'"w 'Sl s " Address If different from ( location) ; • city/Town Skate r Telephone Number � �d Bo Pumping Record,71 t rA r� <� pate of Pum in ' p g date 2. Quantity Pumped: Gallons 3, Type of system:. Cess0061(s) Septic Tank Tight Tank � r '®ther(describe),� �•. � 4. Effluent Tee Filter present?. Ye,.,, No' If yes, was it cleaned? ® Yes ®' No 5 Condition of S st m r r 6 31rNjumped By� h� i r Vehicle Licen*e Number Company. r ;; s' � `` •', r r';, • f�J �� • 7 Local on where contants•werg disposed: Signature of Hauler, �: [late http/frvrvw mass gov/dept aier/approvalsit5forms,htm#inspect tfomA.doc/p81p3 System Pumping Record•Page t of 1 .omrr onwealth7 of Massachusetts City/Town Of NORTH AN U T a _ a yt Purr�pin r Form 4 f CEP has provided this form for use by local Boards of Health. The System Pumping Record mu be submitted to the local Board of Health or other approving authority. A. Facility Information a— ---__—____-- Important: When filling out System Location: forms on the only the tab key Addr--- _ & � �, � � �644! _ - ess to move your cursor-do not ----.-----_____._____. use the return City/Town State Zip C - ode key. Zip C 2. System Owner: Name __._..___ _.-.__ .------ _----- Address(if different from location) State Zip Code Telephone Number B. Pumping Record _ ------ 1. Date of Pumping pat - 2, Quantity Pumped: Gallons ,.. .w.. Type of system: ❑ Cesspooi(s) a~ eptic Tank ❑ Tight Tank ,a ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑- o if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 1 " Sy em Pumped By: Namef Vehicle License Number a ��YJ1q Company 7. Location where contents were disposed: Si ature of Haul _.. Dale http://www,massl.gov,/dep/water/ provals/t5forms.htm#inspect t5form4.doc-06/03 System Pumping Record- Page 1 of y ,a 1 it a U A�""a ��7 t��tl F t f''"� G"t f .......... °ti MA ruKu of „Pvx`"""K'"d �'b�rA1,l�`I,"�ddsr� R PrdP.,d��ti_IV.C�2C.'1" FMAVY �dwrce f � r cum rurq in DLA NOPP(H lip IL A .�P TOVVN OF (U. SYSTEM PUMPING RECORD DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) CS, I � / DATE OF PUMPING: QUANTITY PUMPED : l GALLONS CESSPOOL: NO YES 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: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: .L. . Lowell Waste TOWN OF NORTH AN'DOVEk UL A tl � n„,. � SYSTEM PUMPII^ Q R.EC oRi) az ;W SYS rEM lJ1A✓NF,R ds ADDRESS SYSTEM LOCATM(7N Y DATE OF PU NQ;�. . . m_..._QUANTITY PUMPED; k.'E11PO0L: NOaw..... ....YES., ....,. SOPtic Tank: NU YES.. N^ rURU OF 5BRVIC8: R0u'rI.Nk.,._. _...1;'M8RUENC'Y .......... OBSERVATIONS; CONDrrIUN FULL ,�COVER HEAVY O. B . ... FAMES IN PLACE, 'ROOT'S LRACKRUD RUNBACK BXCUSIVE SOLIDS.._.. FLOODED SOLID CA YOVER,_,....,OTHER EXPLAIN 5y*lvm Pumped by WMME.NTS, CUN I'Wrs rKANSFbRKBD I*U �T4 rx z u z IICl) zo C4 OR rz p PC rz z uo o ;? rn W �2 A U z 0 Im u r m > C) �, U 0 CC*- � Pr cn tZ co 4 fir° to p� � 0.d . • �• - 0e d ` > C4 0 ca o of •1 ♦� r ;�y r 1 C e a W zo A O �" \ > a � � etc E= U W � aG: ACS a6=, UG� W C' z A •. � ""*�" "`� Gar a �'' �' W e•" c� il :z r r� 6 B r a �y W if