HomeMy WebLinkAboutSeptic Pumping Slip - 67 VEST WAY 8/1/2016 �LN Commonwealth of Massachusetts
City/Town ®f
System Pumping Record NOV 10 2009
Form
TOW OF NOR'rli AND()VyER
DEP has provided this form for use by local Boards of Health. Other for ❑ �
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 of other approving authority.
A. Facility Information
1. System Location: Left side of hour, Right side ctf house-,Left front of house, Right front of house,
Left rear of house, Right rear of ho se-. Left°rear of building. Right rear of building.
Address
----- ----- — ----
ce) 11 - U Wn-" �jC741A.-I'VINI-
Cityrrown State Zip Code
2. System Owner:
Name ------ ---
Address(if different from location)
--
-------
----------------
City/Town Skate �4 M Zip C e
Telephone Number
B. Pumping Record � � ❑ .�.�,
1. Date of Pumping - - 2. Quantity Pumped: -� - -- -
Date _ Gallons
3. Type of system: ❑ Cesspool(s) .0-Septic Tank ❑ Tight Tank
❑ Other(describe);
4. Effluent Tee Filter present? ❑ Yes ❑'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S stem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc______
Company ---- --
7. Locat' w,t er. contents were disposed:
G.L.S. Lowell Waste Water
-----------
Signature of Hauler Date
t5form4.doc-06103 System Pumping Record a Page 1 of 1
Commonwealth Of Massachusetts
CityfTown of
�'
a System Pumping cr
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
Important: - .
When filling out 1. System Location: Left front, left rear, left side of house. Right front, right rear right side of house. 1
forms on the _ . .., -
computer, use _
only the tab key Address r� q
to move your t�r 'l,'�1 =; `. .° "ti•_.., 11v - (�
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
AA
Name --
ietvn
Address(if different from location)
City/Town StateZip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) Septic Tank Q Tight Tank
Other(describe): -- —-
4. Effluent Tee Filter present? 0 Yes.p-"Vo If yes, was it cleaned? Yes Q No
5. Conditio System:
0m / ._
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S. Lowell Waste Water
Yigna Date
t5form4.doc^06/03 System Pumping Record•Page 1 of 1
� ..
Commonwealth f Massachusetts �.� ;
City/Town of �
System on Record �
Form
y
Boards fom�ia
DEP has provided this farm for use b local ards of Health. Qt""�r s may be used, but the
information must be substantially the same as that provided here. Before
using this form, check with year
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
Important:
When filling out 1. Syste Location: --.
- �� 2
forms on the
computer, use
only the tab key Address b r
to move your —
cursor-do not CitylTown S e Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone lNumber
B. Pumping c r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) optic Tank ❑ Tight Tank
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes ��Na If yes,was it cleaned? ❑ Yes ❑ No
5. Condition P T Syster:
6. Syst P mped By: �-
Name ` Vehicle License Number
Company
7. Locatio here coan-7 w Msposed:
�
Sign re o u
Date
t5form4.doc<06/03 ll System Pumping Record•Page 1 of 1
Commonwealth of M S chu tt
City/Town of I
System u In Record
Form 4 f 1 X11,
f t
I
DEP has provided this form for use by local Boards of Health. The System Pump hg'kecord must
be submitted to the local Board of Health or other approving authority. �d
A. Facility Information
Important:
When filling out 1. System La atio
forms on the w
computer, use _
only - -
the tab key Address —
to move your
GUfSaf-do not
use th&return Cityrrown to Zip Code
.key. �,..
2. System Owner:
Name -- — — - — — --- ---
Address(if different from location)
Citylrown Stat� _ "dip Cade
Telephone Number
B. Pumping eCOrd
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 < o� If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System ,� J ° 4
V
6. System Pum ed y`; .—
Name Vehicle License Number
--
Company ----
.7. Location re c�rntentse dip ed:
Signa re ler Date
http://www.mass.gov/dep/w er/approvals/t5forms.htm#inspect
t5form4.doc<06/03 System Pumping Record.Page 1 of 1
I
TOWN OF
SYSTEM PUMPING RECO"
DATE: "
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
� a n
�(r r.
DA'T'E OF PUMPING: �_ �� 1� QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE AFFL S IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OT HE R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONTENTS sFE E D TRH. . . Lowell Waste
TOWN OF P, v
SYSTEM PUMPING RECO"
DATE: ._ ,-
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: QUANTITY PUMPE TD : � � GALLONS
CESSPOOL: NO YES SEP'T'IC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEAC HF 1E LI RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OT +R(E L
SYSTEM PU ETD BYt Bateson Enterprises, Inc.
COMMENTS:
NTS:
M�
CON'T'EN'T'S TRANSFERRED TO:
TOWN OF NORTH ANDOVER-
SYSTEM PUMPING
DATES""
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
.. ��
(example: left front nt of house)
(r " i
DATE OF PUMPING: UANTITY PUMPED GALLONS
�F
CESSPOOL: NO J YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: s � _ "