HomeMy WebLinkAboutSeptic Pumping Slip - 50 BROOKVIEW DRIVE 10/28/2013 Commonwealth of Massachusetts
City/Town of 0 , ° 01
° System Pumping Record -r N F )MAND:VER
Form 4 HEi
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. 1
A. Facility. Information
1. System Locatiodda"�
Rig ro t of ho Left/Right rear of house, Left-/right side of house, Left/
Right side of buiLeft/ i`gh tont of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner:
Name
i
Address(if different from location)
Cityrrown ' Stat' Zip Code
Telephone Number
7,
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Type of system. ❑ Cesspool(s) ❑'geptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiorl of ystem
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatygawere contents were disposed:
-11
G S. '� Lowell Waste Water
cY
Sign t e Houle Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Z, Commonwealth of Massachusetts
_. P 2
City/Town of � � �"
"T' i Gi1'f"'i'i°i ANDOVER
System Pumping Record !A TH R PAi N
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
Important:
When filling out 1. System Locatio rLeft�fron left rear, left sid of house Right front, right rear, right side of house.
forms on the
computer,use
only the tab key Address ���, .�'�— � 1 q � � _ J� 1 ` �°°��-° � ,r~•-
to move your K.-"'
Cursor-do not ._.-----
use the return City/Town State Zip Code
key' 2. System Owner: ---
Address(if—different from location)
CitylTown Sta r ,i Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: _L
Date Gallons
3. Type of system: Cesspool(s) eptic Tank Ej Tight Tank
Other(describe): --- --- __
4. Effluent Tee Filter present? rj Yes M'No If yes,was it cleaned? Yes No
5. Condition of System:
- — --- —
6. System Pumped By:
Neil Bateson _ E 5821
Name T _ Vehicle License Number
Bateson Enterprises_lnc
Company
7. Locatio w�contents were disposed:
.L.S.D Lowell Waste Water
- - -
igna ure of H u r Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
rs
mm^
City/Town of
System Pumping Record am(l
Form 4
DEP has provided this form for use by local Boards of Health..M°" t ;tem°'mPr
Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling formsrolert use t 1. SySteM aki f
computer,
only the tab key Address
to move our ) (;_� `�
cursor-do not ..__.._ .. —St
use the>return City/Town State Zip Code
key. 2. System Owner:
Name
Address(if`different from location)
City/Town st Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping aa%e__ _.__-_� 2. Quantity Pumped:
Lallans
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
. 6. Condition of System:
6. System Pumped By"
Name Vehicle License Number
Company
7, Location where contents were disposed:
Signature of Hauler Date _.
- --_
http://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
i
t5fom4.doc-46/03 System Pumping Record-Page 1 of i
I
TOWN OF 9
SYSTEM PUMPING CCS
DATE: L k
t
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
(example:left front of house)
PCr
DATE OF PUMPING: ,� QUANTITY PUMPED : ( J 06 GALLONS
CESSPOOL: NO ,J YES SEPTIC TANK: NO YES ✓
NATURE OF SERVICE: ROUTINE--Vl EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIUULD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: