HomeMy WebLinkAboutSeptic Pumping Slip - 157 OLD CART WAY 8/9/2016 Commonwealth of Massachusetts 'T I
of
City/Town a at.Fi v ��, t�a�OV ER
System Pum in Record NORTH ANDDVE � ° �z� . �!�t q�
Sys p g
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
when filling out 1. System Location:
corms the 01q C
computer,r,use
only the talc key Address
to move your State
- Zip ade
cursor-do not CityTrown
use the return
key 2. sy!sJte-�m,�Owner:
-------- ---- - -
_ - - -
Address(if diNerent
-from location)
St to
-- Zip Code
I phone Number B. Pumping Record
-�-3 _..__— 2. Quantity Pumped: i
1. Date of Pumping Date!
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present?VYes ❑ No If yes, was it cleaned? C54 Yes ❑ No
5. Condition of System:
6. System Pumped B
��(J gw6df River Envi�> tat ��s_ _ -
',w'e-- 163 - - - Vehicle License N er
R1VBT X14
Com a
A.WW—tern v
(sloucester, MA N939 re disposed: G•
7. Location where conten s w �+�5.�•
_ NoM Mdode
- _. _.... ...S).1. f 3- - -
Sfg+za ure oeN ler
Signature of Receiving Facility
System Pumping Record Page t of t
t5formel.doc•QW06
Commonwealth of Massachusetts
C E I V
City/Town of
System Pumping Record r. r;.
Form 4J fitc�,
DEPA
DEP has provided this form for use by local Boards of Health. Other forms 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: eb/Right<ran of houseft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Righ front of building, Left/Right rear of building, Under deck
Address L AJ.-A2:�,dd W
Cityrrown State Zip Code
2. System Owner: v
Name'
Address(if different from location)
Cltyrrown state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 1 5^ l Quantity Pumped: Gallons' ''
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee f=ilter 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. 7Locatl n-w ttiere contents were disposed:
S. / Lowell Waste Water
� - � 5r13
Slgn t e cfHaulev Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
h of Massachusetts
� Commonwealth
City/Town of
System Pumping
Syst in p 9 Record
r` 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 Locatio . Le / jgWKo t of house, Left 1 Right rear of house, Left/right side of house, Left 1
Right side of bui g, Left 1 Right front of building, Left/Right rear of building, Under deck
Address y 7.,,�
Cltyffown fate Zip Code
2. System Owner: VtAe.A[ _
Name
Address{if different from location)
Cityrrown State Ep1 6e
Telephone Number ll
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Dlo If yes, was it cleaned? ❑ Yes ❑ No
5. Copdi 'on of Sy tem:
LAA
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G. S. Lowell Waste Water
Sign'to'e Haule pate
t5form4.doc•06103 System Pumping Record•Page 1 of'I
.C\- Commonwealth of Massachusetts
XOM, City/Town of
a
System Pumping Record
Form 4 ;.E
DDP has provided this form for use by local Boards of Health. Other f 'ms may be used, but the
information must be substantially the same as that provided here. Bef rt��this"frr�r; hk ith your
local Board of Health to determine the form they use. The System Pu ' `°�� f fitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System LocatGW-Za of hou right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
Cilylrown State Zip Code
2. system owner:
Name
Address(if different from location)
City/Town S#at � `�,Zi/p Code
Telephone Number I
B. Pumping Record
1. Date of Pumping �Cate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 21' No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f Sy tem:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company - -
7. Location where contents were disposed:
S: L ell Waste W
Slgnaturl�rtu ler Cate
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
C ity/Town of
u° System Pumping Record
Form 4 ,`
DEP has provided this form for use by local Boards of Health. Other for ,
information must be substantially the same as that provided here. Befo LN h your
local Board of Health to determine the form they use. The System Pumping fitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, front of ho , Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address / /~ 7 0
City/Town [ State' I T Zip Code
2. system owner:
Name
Address(if different from location)
Cityfrown 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
J. Conditipq Of�y_Sterl]: q' /�, 7�/ `— k�24.0('-4 c4s I 1;1 `
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LOcatlo here contents were disposed:
VtueLowell Waste Water
r Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of'Massachusetts
City/Town of I
System Pumping Record
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. Systevi Location:
forms the kc)cC � . ,
computer,use
only the tab key Address
to move your
cursor-do not Gi (Town
use the?return � State Zip de'
Ivey' :2. System Owner`
as
Name
Ili
Address(i(different Pram location)
CitytTown state de
Telephone Number
R Pumping :Record
1. Date.of Pumping Gate 2- Quantity Pumped: Gauaris KS
3. Type of systeiv ❑ Cesspool(s) '.��ic Tank.-
- p ❑ Tight Tank
[❑ Other(describe)::
4. Effluent Tee biter present? ❑ Yes 2-9 . if yes, was it cleaned? ❑ Yes"'❑ No
5. Condition of Systerti.:-
6. Syste Pu pe By;
Name Vehicle°hicense Number
7. t ocatio " hei a col den re used:;
Signa re N ter Date
http://wwW,mass.9py a Iwa erLapprovalslt5forms:htm#inspect
t5form4.dnc•06103 System Puriping Record•Page i of 1
TOWN OF
SYST IYI P PING CO
DATE: -64
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
DATE OF PUMPING: QUANTITY PUMPED : 1 _ G LONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACIUIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED ay: Bateson Enterprises, Inc.
COMMENTS:
col%=NTs=ANsFERRED To: G.L.S.D Lowell Waste
Form 4 -- System Pumping Record
Commonwealth of Nlassachusetss
Massachusetts
&stem Pumping Record
System Owner System Location
Type: Emergency Routine
Cesspooi: No Yes Septic tank: NO Yes �
Date of Ramping: , Quantity Pumped: a Cllbt(j Gallons
System Pumped fay: Wind Riyer Environmental, LLC Permit#;
Contents transferred to:
Contents Disposed at:
East Fitchburg
Waste
An
Date: Pumper Signature:
Condition of System/Other Comments
Dep Approved From - 12107195
�('onuri mwe illy of Massacl�usetts
Massachusetts
System Pumping Record
System Owner System Location
C�
Date of i'untpillg .— Quai#tity Pumped: l�C�gallons
CesspooV No Yes Septic: Tank: No Yes
System 1'limped by: 54rejart License #
Contents transferrred to : Greater L.awrerice $aititery District
Date: _� Inspector: