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Home My WebLink AboutSeptic Pumping Slip - 74 STONECLEAVE ROAD 8/10/2016 Commonwealth of Massachusetts N, City/Town of System Pumping Record [1AY ' N1 Form 4 H FrUMJ7 11J, 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 farm 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�rearf Left/right side of h ouse, Left Right side of building, Left/Right front of building, Le uilding, Under deck Address ❑ �� .c,�� . C..,�� ' -�. cW..a`'�c_' C _ Citylrown //State Zip Code 2. System Owner: 1 Name Address(if different from location) Citylrown ' State Zi c Telephone Number I e B. Pumping Record L( 1. Date of Pumping Irate 2. Quantity Pumped: Gallons 3. Type of system; ❑ Cesspool(s) ® eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep o if yes, was it cleaned? ❑ Yes ❑ No " 5. Condition of System; f ��' p �❑ 6. System Pumped By: Neil Bateson F6821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed; S Lowell Waste Water , �*n$tufe 4 Haule Date i 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 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 igllr�ar of hgusi� Left/right side of house, Left Right side of building, Left Right front of buildin%�, �Legfth/�R ig�t rear of building, Under deck Address .......... City/Town State Zip Code 2. System Owner, A-ZIA Name Address(if different from location) Cltyfrown Stat" �'p Z' Co e Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system- ❑ .Cesspool(s) D-'Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee I Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes F-1 No 5. Condition of.system- 6. System Pumped By: Nell Bateson F5821 Name Vehicle Licens Number Bateson Enterprises Inc Company , t,�'[? 1 (3 2()1 3 7. Locatio here contents were disposed: TOWN OF NORMAINDMER HEALTH DEPARTMENT Z' Lowell Waste Water -3 Sign t eAHaulel&-b Date t5form4.doc-06103 System Pumping Record•Page 1 of I Commonwealth of Massachusetts City/Town of System Pumping Record p Form.4 DEP has provided this form for use by local Boards of H a � , used, but the information must be substantially the same as that provi �e i ere,.-� l�q 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. d�. Facility Information Left front of house, right front of house, left side of house, right side of house, Left 1. System Location: ar"of haus:,-left side of building, right rear of building, under deck. rear of house ff ht r _ City[Town State Zip Code 2. System Owner: - f Name Address(if different from location) :--_ ___ _ City/Town State Zip Cade Telephone Number e(� B. Pumping Record date Quantity Pumped: Gain 1. Date of Pumping — _._- 2 - i 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes U No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6, System Pumped By: Neil J. Bateson _F5821 _ Name _- Vehicle License Number Bateson_Enter prises Inc. Company 7. Location where contents were disposed: _:,S.. Lowell ste ter auler Signa u of Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth'of Massachusetts City/Town of - System Pumping Record � C �� ' l Form 4 ,,,JUL 0 8, Z009 DEP has provided this form for use by local Boards of Health. Other f a�used, but t information must be substantially the same as that provided here. Be 19XSek ith your local Board of Health to determine the form they use.The System Pu ptrf �C d'1�tIsM ,sub itted 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, ight r ) right sid f house forms on the computer,use only the tab ke to move your y � Address cursor-do not —._ __..__. _ ...__� use the return Cityrrown State Zip Cade key` 2. System Owner: _ Name Address(if different from location) CitylTown State/,«� �y , �� Z Code Telephone Number B. Pumping Record Date � 1. hate of Pumping � 2. Quantity Pumped: -- - Date . _ Gallons 3. Type of system: Cesspool -s) Septic Tank Tight Tank Other(describe): - - — R---- 4. Effluent Tee Filter present? 0 Yes BIN. If yes, was it cleaned? [ Yes ( No 5. Condition of System: 6. System Pumped By: Neil Bateson F 5821 LL- Name Vehicle License Number Bateson Enterprises Inc __..__- Company 7. Location where contents were disposed: L.S.D Lowell Waste Water j igna ure of H u r Date t5form4.doc•06103 System Pumping Record-Page 1 of 1 , , Q ,,, ' e, umplCr ' ecord r(�1, •5 ,r'��i'� (( •'fy n51r�14.,t'y41�'„ �'ij�( •^j , DEP,ha� provldad thl� form for use by local wards of Health. The,Sy rr� em Pumping R©core us; be Submitted to the.local'Board of Health or other approving authority, >5 A%,.Faci(1ty lnfo�iNtion JryYr«on'faun;out 1 System lroC&tlonr , �r',�uset only the tab key Address to move your w our r•do not Clky/T 7 the' tum .w n State .'.r: P Pode M1P .System 4uine,r,':;:,•.�'�, ',;;; y . �:YY .� ,5 S. •��".,r t'ey'rrt.•�� 5.S r♦.t'f'r�_J� .:i � J^4 rtr � ^ . Nsm1 c'i:Addrasa(If Merent from location) . Ctty State• p � ( -- dJ ' rT ' Telephone Number i RUM. iepord' y 1 DakQ'of Pumpinq `-- Dek e 2r Quant! Pumped: Gallons Type of systemi'; ❑ casspaol(s) Septic Tank ❑ Tight Tank • � �jOther(descr(b�j '"� ' , 1 Y;rHAr - Effluent Tee Filte prYsent? Ye I too I yes, was it cleaned? ❑ Yep No 11 7 d f e -;.Cori'tlitton'ot;Syst m;'' `.«. r ' � � .i J .4«G �Y.i.�Yl;�a 4G J rN;7.�fi•r;{i(t�"�f5,w t + ^ Pumped Syr + ••{„ ./j{, + { i. �f 7+5,4'x1 }/"1 ' '';.: 5 �rJ J 5.: 4 rr. !r. IAYI!/f+...✓r I 4� r. .r �kt yhx F�JJ �J1' ;.1�;�.�}',.u"r•+,�,r'i J'yl' v :CFtiS+ !s ' `��tR'�j„��rJ, �� i.;'a' i' •� %�'�t>9 f /"#Veh1C�9uCbn#eNumber ! ir, J �4Af}i lrirr5 ',, .lw�y,d {r•'�7 1 (�� r 'v�f..',' ', (.oUOQh when contents'Were dl�posed; ,''� !, , I ( r .it^+Ivta. ,} ,. 1,t 5••, J 1�' r 45 rf jfY�1N 5>,4J E ? in � .r• rt ��`. y F � r , I J� r r 5; 5 iG' t15 ♦ra1J !r .j r+it C}�' t r t l 1,}f r, tJ , 5 J, t4 �; J3 , �rSJV rk- d�•. rfr . r , rir,�r.4.'r,J. /�, -7*� iF—.y. ar "yr.t.ri';Slpnalure 0(Maute(�'A IfN'� '...,..1 Data ! G1./yL-• �.__.�._ fts VE is- htt�iJh+vivw,mass,gov/ gp wafer/a pprQYa'js//t5formsrhtm#inspect t5forrMS doe 08IQJ r , System Pumping Record Page i oP , TbYM OF NORTHANDOVER SYSTEM PUMPING IFCOR_D �) �'HM OWNER & A SS SYSTEM LOCATION (examPIe: Icf( from of house) U:v'IT OF PUMPINC:� s` � ._ QUANTITY PUMPED /� LI,(�� , NO YES SEPTIC' TANK: NO YES b0. 4---. 'NATURE OF SERVICE: ROUTINE EMERGENCY t111.��'(ZY,�TI©NS. GOOD CONDITION. FULL TO COYEk HRAVY CREASE BAFFLES IN IlL,ACb' BOOTS LEACHFIELD RUNUACK... EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER ( HF;R (E;XPI.A.IN) �)'�TLI.m PUMPED BY: ILI lzz�—, Y j O-N'11:'NTr TIZANSFC, RR ED TO: