HomeMy WebLinkAboutSeptic Pumping Slip - 94 SHERWOOD DRIVE 8/1/2016 Commonwealth c�® a rr„r n-�:mwrm:�o,^unmmIDi mwre ,
v City/Town
System Pumping Record
?014
Foy 16:;Roo OF NORTH MD OV R
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HEALTH b PARTPAFh9T
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DFP 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 ght front of hour , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Le /Rig of'building, Left/Right rear of building, Under deck
Address � � „
City/Town a�4ate dip Code
. System Owner:
. ,- '
Name
Address(if different from location)
City/Town Late odye
Telephone Number
B. Pumping r 1
P d Quantity Pumped:
1. hate of Pumping ate � Gallons 2. . '
3. Type of system: Cesspool(s) EY Septic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? Ej Yes Ej No
5. Condition of stem:
6. System Pumped Sy:
Pfeil Sateson F5821
Name Vehicle License Plumber
Sateson enterprises Inc
Company
7. jSigntu THe contents were disposed:
Lowell Waste Water
bate
t5form4.docm 06103 System Pumping Record m Page 1 of 7
Commonwealth Ith Of Massachusetts �
City/Town Of
a °
System Pumping Record u°"d
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 Infer ti®n
1. System Location: Left i ht front of houEuiliding,eft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ Rig ran o Left/Right rear of building, Under deck
Address
L 4 . —
City(rown State Zip Code
2. System Owner;
Name
Address(if different from location)
City/Town State " Cade
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Q enk ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes EJ -o ' If yes,was it cleaned? ❑ Yes ❑ No
5. Conditioxi of System:d�-
1ki 6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Location, h e,,contents were disposed:
L Lowell Waste Water
Sign to a Haule Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
City/Town of m �w"
System Pumping
4 Fora
iy
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 hare. 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 m n. 2
forms
com puter,
use �
only the tab key Address n
to move your
cursor-do not
use the return City/Town S e Zip Code
key. 2. System Owner:
tad
Name - -
r Address(if different from location)
Cityfrown State�y � �-�, t Zip C e
Telel/phone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
p g Date Gallons
3. Type of system: ❑ Cesspool(s) -Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiop of S stem: 1� (" '� CA CA m
6. System Pum By:
Name
`V � Vehicle License Number
Company
7, Location here c/\(r'��ntent ere l osed:
JCIZ
Signature H Date \\VUJII
t5form4.doc^06/03 System Pumping Record m Page 1 of 1
TOMW OF
SYSTEM PUMPING REi CORD,ECEIVE6
FEB 2 3 2005
DATE.-
.
C1` N Or m Aid d ANDOVER
HEALTH bwPARfMEaN
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:ple:left front of house)
DATE OF PUMPING: QUANTITY PIJMPE D : � GALLONS
CESSPOOL; NO � .w.� .� YES SEVrIC TANK: NO YES .
NATURE OF SERVICE; ROUTINE �:.., EMERGENCY .
OBSERVATIONS:
GOOD CONIDITION I�`ULL TO COYER
HEAVY GREASE _ BAFFLES IN PLACE
ROOTS I:EACI�IE`II7 L D RUNBACK
EXCE SSIVE SOLIDS FLOODED
SOLIDS CARRYOVER _ OTHE R(EXPLAIN)
SYSTE M PUMP]ED BY: Bateson Enterprises, Inc.
COMME NI'S:
CONITNTS TRANSFI;RREID TAD: .Le . Lowell Waste
MIT;? littlik ar in6whis
r
JIM )v
QUA HIPY Pq TIPF)
k A
CUKHA V I h4h
Y) MAO 1 2 2005
Stu T CAKk ygyq, EM AM
I 1Y
..........
k, q
I MINIM K
TO" OF NORTH ANDOVER Qw,
SYSTEM PUMPING CORD
A'i
1 STEM OWNER & ADDRESS SYSTEM LOCATION _'----
(example: left from of house)
A P C2.
v �\'I,C OF PUMPINC: � e'llo �.. QUANTITY 'PUMPED 0/� LLU.'�
C. �.5100L: NO YES SEPTIC TANK: NO — ` — YES
t.
ATURE OF SERVICE: ROUTINE EMERGENCY
uu3 FRV,:1TIONS:
GOOD CONDITION, FULL TO COVEk
HFAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER NHER (EXPLAIN)
i
EM PUMPED BY:
MrNTS:
U^' I'l:'.'v''I S `l'IZANSFEIZI ED TO:
TOWN OF NORTH ANDOVER �
SYSTEM U N RECORD
.p . �
DATE:
SYSTEM OWNER cot ADDRESS SYSTEM LOCATION
(example:e. left ronV t of house)
M
DATE OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO ° k'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: