HomeMy WebLinkAboutSeptic Pumping Slip - 116 SHERWOOD DRIVE 8/1/2016 Commonwealth f Massachusetts
City/Town of
u
System Pumping,
Form 4
\L
®EP 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 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, Le 1 ht rear of house yeft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Righ rear ofi building, Under deck
Address j
City/'rown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' State ,r ~� de
Telephone Number
B. Pumping Record
1. Date of Pumping g 2.Date Qu antity,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. Conditia of SAM*
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location hhere contents were disposed:
L S'. Lowell Waste Water
4
Sign a Haule �. Date {
t5form4.doo•06/03 System Pumping Record•page 1 of 1
Commonwealth Massachusetts (. It r
a
City/Town of
a r'
Form 4
r
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 house, Left ht rear of ha , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State 7 � C d
Telephone Number
B. Pumping Record
~ C"
1. Date of Pumping 2. Quantity Pumped: Gallons
Date
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 ys m: w,
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.j8lgnt here contents were disposed:
, Lowell Waste Water
Haule Date
t5form4.doc•06/03 System Pumping Record^Page 1 of 1
Commonwealth Of Massachusetts
City/Town of
System i 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 house, LefG".Rigb rear of hour; ;Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
A
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town '''^� `� '�w State Code
f, „4 } Telephone Number
B. Pura in 41161 ord
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 [Dli6 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 where contents were disposed:
I L S.:°:. ...`" Lowell Waste Water
Sign to a Haule Date
t5form4.doc^06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts ......
u City/Town ®f
System in
DEP has provided this form'for use by local Boards of Health. Othe "" e
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 Left/ I
y g �ght fear of house, Left/right side of house, Left/
Right side of building, Left/ Right front of building, igt l-Right-Te'6r of building, Under deck
Address
City/Town State Zip Code
2. System Owner: w
Name
Address(if different from location)
City/Town Statte� Zip Code
Telephone Number
B. Pumping Record ve
1. Date of Pumping Date 2. Quantity Pumped: Canons
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. Conditi n f S stem: (
f ..
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc Lion wheje contents were disposed:
G.L,S.p Lowell Waste Water
C.
IaA
_ . .
Sign toe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town Of
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,ReC6{',�iin6i t"k e ubmifted to
the local Board of Health or other approving authority.
A. Facility Information l
1. System-Lam u
tion: Left front of house right front of house left side of he s ri htistde of rt uusi ft
rear of hou5 , right rear of house, left side of building, right rear of building, under deck,
City/Town State Zip Code
2. System Owner;
Name --- —"�-- —
Address(if different from location)
City/Town - State Z wC e
Telephone Number
B. Pumping ecor
1. Date of Pumping Date - — 2. Qgantity Pumped: " ----
Gallons
3. Type of system: ❑ Cesspool(s) El 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:
_61A (110A)__04 ., f
1
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. catiprh, here contents were disposed:
G.L.S.D. A0411 Wast r
I/k"
Signature of a ler Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
City/Town ®f RL[TOWN a ^Ar
System Pumping Record
N �H AN �r F�rn 4 r 1
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 sideof_ e, Right side of house, Left front of house, Right front of house,
Left rear of house, t rear of hour Left rear of building. Right rear of building.
Address j V ` 'r�/ _
City/Town State Zip Code
2. System Owner:
Name _
Address(if different from location)
City/Town State Zip Code
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:
�Ij
6. System Pumped By:
Neil Bateson 175821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati mere contents were disposed:
L .D Lowell Waste Water
g to a 4Haul Date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
M1y4
Commonwealth Of Massachusetts
City/Town of Ilu � .. . ..
System Pumping r
Form 4
NAAY 6 2("Y"19
DEP has provided this form for use by local Boards of Health. Ot ef�Qfgrts Re0P Is %:tit he
Befire
Information must be substantially the same as that provided here. r �, ck 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: q .
When filling out 1. System Location: Left front, left rear, left side of house. Ri g ht fro Q t'rght re ,wr ht �,...
f haus�..
forms on the ( 1
to move you
only the tab j key Address
computer, use (
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner: 1
------ Name --
4M _ Address(if different from location) R
City/Town State _ 7_is Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date . Quantity Pumped: Gallons
3. Type of system: Q Cesspool(s) peptic Tank p Tight Tank
Other(describe): -
4. Effluent Tee Filter present? El Yes 4Ej No If yes, was it cleaned? [ Yes No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
'y .L.S.D Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts ....... .........
City/Town of
System u i Record R kA
Fora
by
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 for,,check with
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 the filling the out 1. System ac \4�✓✓ •.� �,;�.m, /`
computer, use J
only the tab key Address ,•..�
�� / .. ✓
to move your � � �'"� ,, a �.� `, �...`°��, R � C..� �,�'•...� d
cursor-do not City/Town State C Zip Code
use the return
key. 2. System Owner:
0
Name - — --
Address(if different from location)
City/Town State „
� Zip ode
61� ') �3r aw
Telephone Number
B. Pumping cord
1. Date of Pumping ®ate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? ..,wm._w.
p ❑ Yes � No If yes, was it cleaned? El Yes ❑ No
Condition of System:
6. Syste Pu ped By' M
Name �
/^�w� �� ,. „ .� � Vehicle License Number
V ....�
Company
7. Location w,ire contents we isposed:
..
Signatyfe pf uler Date
t5form4.doc^06/03 System Pumping Record m Page 1 of 1
Commonwealth of Massachusetts
— f City/Town of
System u in Record
Firm 4
V'l/\"( `a 9 �'UIV
DEP has provided this form for use by local Boards of Health. Other to s1 ma r
information must be substantially the same as that provided here. Befor usi . Is o t,check °witP�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. Systerp Location: d �
forms an the
computer, use
only the tab key Address -
to move your \ `
.. "'
cursor- not
use the return City/Town State Zip Code -
key.
2. System Owner:
VQ - ---- - --
Name .� - ------
" Address(if different from location)
City/Town State Z' Code
Telephone Number
B. Pumping Record
1. Date of Pumping to 2. (quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑'Septic Tank ❑ Tight Tank
❑ Other(describe);
4. Effluent Tee Filter resent? ,.
p El Q" No If yes, Was it cleaned? El Yes ❑ No
5. Condition of System: ;...
d
5. System um ed By:
Name Vehicle License Number
� w
L
Company
7. Location her content s Weposed:
- wM C.
Sign re
;I
uler Date
t5form4,doc^06/03 System Pumping Record a Page 1 of 1
Commonwealth of Massachusetts �
City/Town of I
i �'`0
System mpin Boor
r Form 4
DEP has provided this form for use by local Boards-of Health. 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 Lacat"
forms '
fo on the
computer,use
only the tab key Address
. _ -- -—— —
to move your A�,.. . ,�
cursor-do not "
Cityfrown -- -----
use the;return Stake Zip Gode
key. 2. System Owner:
...
r
Name ----- ------ ------- -—--- --
rtun - m l - —
-------------------------
Address(if different froocation) --
City/Town -- —
State --- --- - --
e ephone Number — — —
13. Pumping oc6rd —
a .
1. Date of Pumping Date 2. Quantity Pumped: —
Gallons
3. Type of system: ❑ Cesspool(s) ❑—& ptic Tank ❑ Tight Tank
❑ Other(describe); --- -- - ---- ------
4. Effluent Tee Filter resent? „ ..m
p ❑ Yes ❑�IVo If yes, was it cleaned? F] Yes ❑ Na
5. Condition of Systeq
z-
6. System Pum ed By �
Ve
Name -- -- -- ------ -----
> hicle License Number
Company - —
7. Location where contents w.,
ere losed:
Sig tur of H ler --
http://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
t5form4.doc<06/03 System Pumping Record•Page 1 of 1
lg z
TOW OF Nil
� 9w�
S STEM PUMPING RECO .. m"
DATE: W.
w
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: (6" U �� QUANTITY PUMPED : 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 L.EACFIFIEL D RUNBACK
EXCESSIVE SOLIDS FLOODED
DEID
SOLIDS CARRYOVER OTHER(EXPLAIN)
sYsum PUMPED BY: Batesion Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D kA Lowell aste
TOWN OF
SYSTEM I
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCA'TIO
(example: left remit of ouse
yw
4 c.A,(2 .a
DATE OF PUMPING: QUANTITY IJ ED °
GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES _
NATURE OF SERVICE: ROUTINE, EMERGENCY
-
OBSERVATIONS:
GOOD CONDITION FULL TO COVE,I2
HEAVY GREASE BAFFLES IN PLACE
ROOT'S LEACH FIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHE R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: -Lm o ,.. ,... Lowell Waste
TOWN OF
SYSTEM PUMPING
DATE , ") ", c
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
�.. (example:
left front of house)
DATE OF PUMPING: °"� �s QUANTITY PUMPE D : �� ¢"° 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 LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHE R(EXPL
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONTENTS TRANSFERRE D TO ('