HomeMy WebLinkAboutSeptic Pumping Slip - 350 BERRY STREET 7/19/2017 Commonwealth of Massachusetts
City/Town of
System Pumping- Record
Form 4
DEP has provided this fora far 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
loc6i 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 Locationtai,'
il ig k6nt of Nous , Left/Right rear of house, Left/right side of house, Left'
-1g
Right side of bul ing;- eft �6ildiri , Left Right rear of building, Under deck
Address v7;1 4
Cityfrown state Zip Code
2. System Owner:
Name'
Address(if d(ffereni"fr6m location)
CitynownLU O"t 2014 State Z*
nT
Telephone Number
B. Pumping Record
C
L
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system-. El Cesspool(s) Septic Tank Ej Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes E3, ko If yes, was it cleaned? E] Yes No.
5. Condition ofSysteal:
6. System Pumped By:
Nell Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Locat. n-w re contents were disposed:
GLLSQ Lowell Waste Water
Sign At4e—f—HauleV Date
t5form4.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 Health. Other forms may beused, but the
information must be substantially the same as that provided here. Before using.th 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
1 System Locatio%Oe /Rig tfC�rdnt o guse�Left//Right rear of house, Left/right side of house, Left
'i, ') f '
Right side of bulling, Left Right❑front of building, Left Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner:
�kj r
Name*
Address(if different from location)
Cityfrown State Z'D
Telephone Number 4
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system'., ❑ Cesspool(s) O—Septic Tank [:1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ET'ko If yes, was it cleaned? M Yes M No.
' 5. Conditio f System:
6; System Pumped By:
Nell Bateson F5821
-Name Vehicle LicenseNumber 'n
Bateson Enterprises Inc,
Company
7. Lo lo, re contents,were disposed:
LS
G G ,7
L Lowell Waste Water
BEV
Sign t a Haule Date
t5form4.doo-08/03 System Pumping Record-Page 1 of I
Commonwealth of Massachusetts
City/Town of
w
System Pumping Record
a` Form 4 `
DEP has provided this form for use by local Boards of Health. 4 fih f`forMay b us°ed;16ut 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:op '7Rightfrq6ri6f h suo 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 r
Cityrrown state Zip Code
k. .
2. System Owner:
Name
Address(if different from location)
. Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 1— 2 uantity Pumped:
Date 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 of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company ,
7. Locatio where contents were disposed:
M. .
GLowell Waste Water
S-
SignAtufe 4 Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusettsw� W � �� 4 M,
- City/Town of
= System Purpling Record
Form 4
i ii�s e
1+1
[H-E.W"A�"i"
DEP has provided this form for use by local Boards of Health. Other for n^ra� usod uL to
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 of other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of hou rLeft ont of house, ght front of house,
Left rear of house, Right rear of house. Left rear of buil M-rearof uilding.
Address _......_ �`�.
City/Town - State Zip Code
2. System Owner:
Name
I
Address(if different from location)
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: .__._.....__
Date 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 of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7, Loca �oth contents were disposed:G,L. w t Waste W ter
SignaturDate
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
4 WO,
DEP has provided this form for use by local Boards of Health. Ot r forms may be used, bu the
information must be substantially the same as that provided here. 08 ck with your
local Board of Health to determine the form they use. The System P ubmitted to
the local Board of Health or other approving authority.
A. Facility Information.....","
1. System Locatiodj:e6fr- , right front of house, left 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.
J2-� -�- , lug,
--A CS
Cityrrown State Zip Code
2. System Owner:
,gym ❑�J"x
Name ❑
Address(if different from location)
City/Town
Telephone Number
--------- —
B.
--------
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: ------------
Date Gallons
3. Type of system: ❑ Cesspool(s) nr`s�-eptic Tank F1 Tight Tank
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes 0--No If yes, was it cleaned? 0 Yes F] No
5. Condition of ys em:
Vx-
& System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
BatesonEnterprisesInc.
Company
7. Location where contents were disposed:
D. ell Waste
Smignatue -,
0 Ha r Date
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
Commonwealth of MassachusettsRECEIVEDuu
. ...
City/Town of110V 1.
system Pumping Record
Form 4wi&�i()uw ' uE
N 8
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 Location L ft front,'jbft rear, left s" e o hhouu . Right front, right rear, right side of house.
forms on the
computer,use
Y
only Y
to move tab Address . p C
cursor-da not City/Town
State Zi Cade _
use the return
key. 2. System Owner: �
Name
Address(if different from location)
—---------------�
City/Town State C Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date __ 2• Quantity Pumped: Gallons
3. Type of system: p Cesspool(s) Septic Tank [j Tight Tank
Other(describe):
4, Effluent Tee Filter present? E
Yes No If yes,was it cleaned? Yes ( No
5. Condition of System: 1
6. System Pumped By:
_
Neil Bateson F 5821
Name -- Vehicle License Number
Bateson Enterprises Inc
Company
7, Location where contents were disposed:
Aigna
L.S.D Lowell Waste Waterure of H u r Date
t5form4,doc•06/03 System Pumping Record•Page 1 of 1
rCommonwealth of Massachusetts --. ... E C �E Dmm
City/Town of
System u s Record
- Form 4 H�W.a H[.)d ���,�MEN r�Fw_
DEP has provided this form for use by local Boards of Health. Other rms-may"be,ttgd;'bU1"'Ifhe
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 Location,
forms on the
onl the tab ke
computer,use Addresg
� -------
.. ,�
to move your y
_._.
cursor-do not — — State Zpod
Ce
J, ,
use the return City/Town
key. 2. System Owner:
Caen Address(if different from Dation)
Cityrrown State C '1 ` C i e
Telephone Number
i
B.
Pumping Record
1. Date of Pumping Date _ 2. Quantity Pumped: Gallons
i
j 3. Type of system: ❑ Cesspool(s) e eptic Tank ❑ Tight Tank
I
❑ Other(describe): —— -
i
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: �
r
s. system Pumped
_..�.By-
Name
- Vehicle License Number _
Company
7. Location w ere contents were i osed:
Signatu of a - Date
t5form4.doc4 06103 System Pumping Record a Page 1 of 1
f
Commonwealth of Massachusetts
x City/Town of I
r
System Pumping Record
_ Form 4 ...
DEP has provided this form for use by focal Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important;
When fining out 1. System Locati n;
forms on the �� �-
computer,use
only the tab key Address
– -----�J ! — _
to moue your
_.
cursor-do not --- _____ _._.._ - // __ _._.
use lh&return City/Town Efate Zip Code
key. 2. System Owner:
Name
Address(if different from location)
Cityrrown State ip ,ode
Telephone Number
B. P-umpi g :Record
(,/)-,
1. Date,of Pumping � - 2
Date - . Quantity Pumped:
Gallons
3. Type of systern: ❑ Cesspool(s) ❑ eptic Tank- ❑ Tight Tank
❑ Other(describe): _.._. --._ ._.
4. Effluent Tee Filterresent?
p El Yes [lNo. If yes, was it cleaned? El Yes' ❑ Na
5. m;Condition of Sys t
C7
6. System Pupedi y
Name Vehicle l-icense Number
�,
Company __._ ____...._
7. ocaklon ere contents
mere l osed;.
s
;gnatur f ul _..
Date
h.ttp://www.mass.govidep/water/approvals/t5forms.htm#inspect
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t5form4.doc+06103 System'Pumping Record•Page 1 of 1
TO I
SYSTEM PUMPING RECO
���k 11,,f
DATE: R ' MAY 2 5 2005—
TOWN Of� f
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
C
DATE OF PUMPING: 4,"( I d QUANTITY PLT ED : C1 GAL SONS
CESSPOOL: NO YES SEPTIC TANK: NO _ _ YES
NATURE OF SERVICE: ROUTINE EMERGENCY
(OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inca
COMMENTS:
CtONTENTS TRANSI+ERRED T®: G.L.S.Dj Lowell Waste
I
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
DATE OF PUMPING: QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES—,EPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIE LD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D /Lo' well Waste