HomeMy WebLinkAboutSeptic Pumping Slip - 26 STONECLEAVE ROAD 8/10/2016 Commonwealth of Massachusetts APR 2,
ti Al'
City/Town of
TOWN OF=NANDOVER
M
HE
System Pumping Record HEALTH DEPARTMENT
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 side of house, Right side of house, Left front of house, Right front of house,
Left rear of hoqs�, R—ight,re4&T�0:-S-6: eft rear of building, R I rear of building.
Address
cD-
City/Town State Zip Code
2. System Owner:
------------
Name
Address if-different-from"location}
-
City[Town Stn
Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) B-t-e-j:�fic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0--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. Location where contents were disposed:
I D7 Lowell Waste Water
490tute-of Haul Date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts RE C � 'AV 1
w City/Town of I
. System Pumping Record JUN :I. . 2,007
Form 4
10i,l ibri ur i :�& i :.
p this form for use by local Boards-of Health. The°Systd, P46n:i�cm r�RIecIor
�����.i .i r�
DEP has provided p g R o d must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling out 1. System Location:
forms on theory4
computer, use __.__
( �.
only the tab key Address
to move your
cursor-do not
use theareturn CitylTown State Zip Code
key. 2. System Owner:
Name
tl _.....__ _ _...—_-----
Address(if d'efferent from location)
City fTown State — _.._
��Zip Codo
Telephone Number
B. Pumping Record
1. Date.of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) tj""Septic Tank [] Tight Tank
[]
Other(describe):
4. Effluent Tee Filter present? ❑ Yes If es was it cleaned?
E] Yes Q No
5. Condition of System:
6. System P roped By ..,.
�- --ilk C
Name " Vehicle License Number
Company
7. Locatio er c
onte w disposed:
- '"
Signatu e o a I r Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5fom14.doc•06103 System Pumping Record•Page 1 of 1
e`
TOWN 9
9
SYSTEM PUMPI G RECORD
�" ... ...o
.... -. '�
DATE i,. V ,
HEN IH r) P'AR-' 'ak.NT
SYSTEM OWNER & ADDRESS SYSTEM[ LOCATION
(example: left front of house)
DATE OF PUMPING: (°L QUANTITY PUMPED : � GALLONS
CESSPOOL: NO YES S l PTIC 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 ateson Enterprises, Inca
COMME NT'S:
CONTENTS TRANSFERRED TO: .L.S'i.13 TILowell Waste
TOWN
SYSTEM PUMPING "CO"
DATE:'?'--?-()'3
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
S4'�L�'? Ck-owe
DATE OF PUMPING: n 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 LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
—----------
6e�- L
CONTENTS TRANSFERRED TO:
Commonwealth of Massachusetts
/V, Massachusetts
System Pumping Record
System Owner System Location
Date of Pumping: –7—9 Quantity Pumped: l '-�gallons
Cesspool: No Yes [] Septic Tank: No [] Yes H—
System Pumped by: 64a"" License#
Contents transferred to: Greater Lawrence SqnItary Distric
Date: Inspector:
commonwealth of Massacl"Isetts
stem i'urn in Record
System Umner System Location
Date of I�klin lll!b Quantity Pumped:
Cesspool: No Septic Tauk: No Wes
System i'umped by: Fd(,edaje ,5rt iaed License #
Cortients traiislerrred to : Greater Lawrence SanitaryVistrlcl
Inspector
FORM - SYSTEM PUN PU\G RECORD
Commonwealth of Massachusetts
, Massachusetts
System Pumping Record
•stern Uwner Systern Location
—ADCA
Date of Pum in `�� ` '� � Quantiv, Pumped: 1� gallons
ping
Cesspool: No Yes ❑ Septic Tank: No ❑ Yes
System Pumped by- License #:
Contents transferred to:
Date Inspector