HomeMy WebLinkAboutSeptic Pumping Slip - 151 CARLTON LANE 11/30/2016 Commonwealth of Massachusetts
C4/Town of RECEIVED
S stem Pumping Record
Y
r - Form 4 C""m1 �. k,
but I
DEP has provided this form for use-by local Boards of Health. Other forms myr' � .>a �
i th'ea7
information-must be substantially the same as that provided here. Before using. Is 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
I. System Location: Le 1kight front of ho , Left/Right rear of house, Left/right side of house, Left/
Right side of buildings lg rant of building, Left/Right rear of building, Under deck
Address ,�,��- rr
F�
City/Town State - Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State-� �,.� �..� 1F Oe,
Telephone Number t
.B, Pumping Record
1. Date of Pumping date 2. Quan'ty Pumped: Gallons ---{--—r
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. Condition of System: Q
6a,
Cj
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo do he contents were disposed:
L S'. Lowell Waste Water
I FA
Sign a I HbulerU Date
t5f6rrn4.doc-06!03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of 0 C I' wo) 01
Sysitem 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
i ht front of hous Left/Right rear of house, Left/right side of house, Left I. System Location: LeK69Ri;�
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address Lv�" e5�VIS&U-1-r
City/Town State Zip Code
2. System Owner: N 0 2015
Name
Address(if different from location)
Cilyfrown St at
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ cesspool(s) ET-fe-ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E2-90 If yes, was it cleaned? ❑ Yes n No
5. Condit, f S St
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G,L S. Lowell Waste Water
Sign e f AHaule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
� System Pumping Record ')W" j gall i"8r XO''l
Farm , ,,
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: Left4l i�ht front of h not h s�, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City own State Zip Code
2. System Owner:
Name
Address(if different from location)
CityPTown State i p ade
Tele one Number
R. Pumping Record
1. Date of Pumping Date ;,.2. Quanti -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 S stem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. iSigntu 771
re contents were disposed:
Lowell Waste Water
Haule Dat e
i
t5form4.docr 06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of R FF.-66-ENVE,5D-
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other foil)
information must be substantially the same as that provided here. Bef el"i ith 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 front of housd�ii`gh6ion f-l=sejeft 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.
-&—yrrown State Zip Code
2. System Owner:
Name
—Address-(if different from location)
City/Town State 'NZip Code
(<'S
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qua tity Pumped: Gallons
3. Type of system: El Cesspools) Septic Tank Tight Tank
F-1 Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes [] No
5. Conditio of System.
wek
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
L.SW.D. ow I Waste ter
1 - L
Signature I ul Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
0 4 System Pumping Record Z9 '1010
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Oth Er :: , he
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ 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 hou<e.�Ikight front of house
Left rear of house, Right rear of house. Left rear of building. Right rear of bufldtrtg���
--- ---------
Address
L
City[Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State ,I
Telephone Number
B. Pumping Record
1. Date of Pumping
Date Z Quant,4 Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 3-S--epfic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes F-1 No
5. Condition S,stern:
0
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
-.--.B.a,te.s..o.-n..,.E..nterprises Inc —------------
Company
7. Loca lijo", 7 contents were disposed:
G.L.S Lowell to Water
Signature ignature H ler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusettsm .
City/Town of ECOVED
System Pumping Record
Form 4
DEP has provided this form for use b local Boards of Health. Other forms j- W
NO::�ti l i ANDOVER
p Y y . � �'
information must be,substantially the same as that provided here. Before u '°'1Fiiso�m, check with your
local Board of Health tQ 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 side of house, Right side of house, Left front of h6-U-se Right front of h ge,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address 1
f m.
Cityfrown State Zip Code
2. System owner: i
Name
.............. _...m._.._ _..._ __.
Address(if different from location)
Cit y frown State Zi Code
Telep one Number
r B. Pumping Record
�- 14
1. Date of Pumping --_._.._..-__ 2. Quantity Pumped:
Date Gallons
3. Type of system: E] 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: q , p l 0
tf 1
6. System Pumped By:
j Neil Bateson ____.,.._. . F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
= 4 = City/Town of l RECEIVED
System Pumping Record
m Form 4 OCT 2 4 2006
N
DEP has provided this form for use by local Boards-of Health. T � 1 rd must
be submitted to the local Board of Health or other approving aut � -
A. Facility Information
Important:
When filling out y _
1. System Locatio n.
forms an the ,, C, �
computer,use 14w, _......r_.."Y
only the tab key Address �F
to move your � (
cursor-do not — � .. .. _
use the°return City Town State Zip Code
key. 2.. System Owner: �
Name .
-----__.
Address(if different from location)
City/Town State Zip Code'
Telephone Number
B. Pumping Record
9. Date of Pumping Date 2. Quantity Pumped;
Gallons
3. Type of system: [Q Cesspool(s) ptic Tank ❑ Tight.Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syst P„ mped y
_._ __ __
Nam Vehicle License Number
Compan
7. Locati where contents were ' sed:
p
Signat a of ul r Date
http://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
f
t5form4.doc•06/03 System'Pumping Record•Page f of 1
I
TOWN F NORTH A /- OVER
SYSTEM PUMPIN RECOR.
�, '11. 2 004
DATE: . �"
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
�/^'+� (example: left front of house)
` � - _
S t C"( LWL/\
DATE OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO I_ YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFI:ELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: - L.
COMMENTS:
CONTENTS TRANSFERRED TO:
I
TOWN" OF K 0 h�-
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM[ LOCATION
(example:left front of mouse)
l
ac
DATE OF PUMPING: _ �? QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES_-L/
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACH FIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OT R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
f