HomeMy WebLinkAboutSeptic Pumping Slip - 53 BROOKVIEW DRIVE 10/28/2013Commonwealth of Massachusetts "'hrn""M"M"Mrnirni"rn
tlii „L!,
City/Town of . • • •
System Pumping Record ocT '25 .'eor3
Form 4 "TOWN (fl NORTH ANDOVE.R
ulEALT1-11 DEPAKTMENT
. M01111111100,111.11MIIIMAIMIMPRINIIII • 1, 1110111111
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, Left / Right rear of house, Left(rgilicSideCTItouse,,Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
,T)
Address
City/Town
2. System Owner:
State Zip Code
Name
Address (if different from location)
City/Town Stat
Telephone Number
Zip Code
er)
B. Pumping Record -7>
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: 0 Cesspool(s) -ScTank Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? 0 Yes 0 No,
5. Condition of System:
e).k-Q•--k-at
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Loc- • •e e contents were disposed:
S.
„: Haule
Lowell Waste Water
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
illl..1,0,101,11100,,,,N,1211,14rnilUI/afe,,,,a,a1,,,,,ftual.rne111,0.001 WO,
Commonwealth of
City/Town of
System Pumping
Form 4
Massachusetts
Record
ECM
OCT 1 6 2012
TOWN NORTt 1 ANDOVER
• tiPALTH DEPARTMENT
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 yourk)
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, Left / Right rear of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building,
Address L6-3
City/Town State
2. System Owner:
Left /
Zip Code
Name
Address (if different from location)
City/Town
Stang
Telephone Number
75ode
B. Pumping Record
1. Date of Pumping
3. Type of system: D Cesspool(s) E1-8(ptic Tank
El Other (describe):
4.
5. Conditio,i Sy, nrkri \i
Date
2. Quantity Pumped:
Gallons
1=1 Tight Tank
Effluent Tee Filter present? El Yes If yes, was it cleaned? D Yes Ell No
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
ign tu e • Haule
F5821
Vehicle License Number
Date
t5forrn4.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 H
information must be substantially the same as that provi
local Board of Health to determine the form they use. Th
the local Board of Health OF oilier approving authority.
ecor
sed, but the
form, check with your
must be submitted to
A. Facility Information
1. System Locati fight side of hous.e.;Left front of house, Right front of house,
Left rear of hous&", Riot rear of house. Left rear of building. Right rear of building.
Address
City/Town
2. System Owner:
Name
State
Zip Code
Address (if different from location)
City/Town
Stat
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: [1]
LI Other (describe):
Date
2. Quantity P mped:
Cesspool(s) a-Terptic Tank
4. Effluent Tee Filter present? 111 Yes
5. Condition f System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location wheresontents were disposed:
G.L.S.D Lowe W Water
Gallons
LI Tight Tank
If yes, was it cleaned? LI Yes LI No
F5821
Vehicle License Number
ignature f ult Date
t5form4.doc• 06/03 System Pumping Record Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
;El E
R 2 3 2009
0 'frit mvix04,Em
.1t1 :7Pxonr,
DEP has provided this form for use by local Boards of Health. Other forms may be useT,Tullge
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 fron ,
Address
Cityfrown
2. System Owner:
left sid of house
\
Right front, right rear, right side of house.
Zip Code
Address (if different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping
2. Quantity Pumped:
Date
Gallons
3. Type of system: 1 Cesspool(s) 0--eeptic Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes lg—lcio If yes, was it cleaned? 0 Yes El
5. Condition of System: j2_tii (A_
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. LocatiQrLwjlere contents were disposed:
Lowell Waste Water
F 5821
Vehicle License Number
igna ure of H Date
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the -return
key.
Commonwealth of Massachusetts
City/Town of
System Pumping Record mid noh
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
1, System Loca on:•
Address
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record r,
1 Date of Pumping
3. Type of system:
El Other (describe):
st
State
Telephone NUmber
Zip Code
41:0
Date
El Cesspool(s)
:6)
2. Quantity Pumped:
4. Effluent Tee Filter present? LI Yes g-Ictic
5. Condition of System:
Avu
6. Systerp Pumped
•
Name
Company
7. Locatio ,whe e content we/disposed:
Signatu ofMauler
http://www.mass.govklep/water/approvalS/t5forms.htm#inspect
CI -Septic Tank
Gallons
D Tight Tank
If yes, was it cleaned? El Yes El No
Vehicle License Number
Date
t5form4.d
System Pumping Record • Page 1 of 1
TOWN OF . � 71\;vtdo,ter
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
53
valk k:64-6L
roob 1)1 -
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING:
CESSPOOL: NO
YES
QUANTITY PUMPED :
SEPTIC TANK: NO
EMERGENCY
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SO() GALLONS
YES
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
Coin,iionwenItl of Massachusetts
oite
Massachusetts
tern Pumping Rccord
L__
System Owner Sy
(—...k.
System Local o
Date of Pumping:
Cesspool: No Yes Li
System Pumped by: i5etredele
Quantity Pumped: / gallons
Septic Tank: No Li Yes
License 11
Contents ttansfettred to : Greater Lawrence Sanitary VistrIct
Date: Inspector