HomeMy WebLinkAboutSeptic Pumping Slip - 70 BROOKVIEW DRIVE 10/28/2013Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
3. Type of system: ID Cesspool(s) 12<otic Tank El Tight Tank
Other (describe):
00TZ t.(4.0 13
To N OF NOR:FHANDOVER
DEP has provided this form for use by local Boards of Health. theT/fCfrptiiii: Giv but the
information must be substantially the same as that provided here:before using.this forrn, 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 i , Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
State
Zip Code
Name
Address (if different from location)
City/Town
B. Pumping Record
t6)
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
Sta
d
Telephone Number
4. Effluent Tee Filter present? El Yes El f<r---- If yes, was it cleaned? 0 Yes El No
5. Conditionryste :
1-t [42'0-ek
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatio ere contents were disposed:
F5821
Vehicle License Number
t5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1
If yes, was it cleaned? 1=1 Yes El No,
F5821
Vehicle License Number
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, Left IhLrr of hotie)Left/ right side of house, Left /
Right side of building, Left / Right front of buildirig, Left / Right rear of building, Under deck
Address 0 csczA
City/Town
2. System Owner:
kj(34-
State •
k-Q--c
Zip Code
Name.
Address (if different from location)
CtEli
City/Town '
.100(--y\m0A 0,0.004004E,R.
u0,00‘...A0A \00.0000p100,F30t,19E1A1'
B. Pumping Record
Date of Pumping Date
Telephone Number
2. Quantity Pumped:
Gallons
3. Type of system': 0 Cesspool(s) Er‘tic Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes
" 5. Condition of Sy
6; System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
Company
7. Locatio
311(
re contents were disposed:
S. Lowell Waste Water
Signtu1 qfiaur(Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
,
fl
7 OVVNq OV NOR11 I ANDovi-uz
DEP has provided this form for use by focal Boards of Health. Other fc_rzantk,Wiii7.11,1f,u4 the
information must be substantially the same as that provided here. Before using this foirn',"aieWwith 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: Leftiroatof house, right front of house, left side of house, right side of house, Left
rear of housi-ight rear of ho, Ieft side of building, right rear of building, under deck.
City/Town
2. System Owner:
u
State
Zip Code
Name
Address (if different from location)
City/frown
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: 111 Cesspool(s)
LJ Other (describe):
Date
2. Quantity Pumped:
Gallons
LJ—ank El Tight Tank
4. Effluent Tee Filter present? 111 Yes Errlo If yes, was it cleaned? LI Yes LI No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises inc.
Company
7. Lpcatioqw ere contents were disposed:
G.L.S
Sign tur o
well Water
F5821
Vehicle License Number
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
EC E
APR 2 3 2009
TOWN OF NORTH ANDOVE
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. OtherrairenTrellITCrtull 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: Left front, left rear, left side of house. Right fror6ht rear) righ
Address (
Cityfrown
2. System Owner:
FA
itate
Zip Code
Name
Address (if different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: 0 Cesspool(s)
El Other (describe):
Date
Lf
2. Quantity Pumped:
Gallons
eptic Tank rj Tight Tank
4. Effluent Tee Filter present? Ej Yes D-AcIf yes, was it cleaned? El Yes 11 No
5. Condition of System:
0
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
F 5821
Vehicle License Number
Date
t5form4.doc. 06/03
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
NOV - 2 no
System Owner
10
bb
System Location
Date of Pumping: k
Cesspool: No /
System Pumped by: V,
Contents transferred to: Greater Lawr
Date:
Yes
4 *
Quantity Pumped: S60 gallons
Septic Tank: No [1 Yes [
License #
nitary DI tr
Inspector: