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HomeMy WebLinkAboutSeptic Pumping Slip - 29 NORTH CROSS ROAD 7/20/2017 Commonwealth of Massachusetts City/Town of Z4 IN14 System r Form 4 DEP has provided this form for use,by local Boards sof 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 6t feat ~", Left-/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Cityfrown State Zip Code 2. System Owner: Name' Address(if different from location) CityfTown ' state - qade-` Telephone Number B. l Pumping gird 1. Cate of PumpingGate 2. Quantity Pumped: Gallons 3. Type of system-. E3 Cesspools) eptic Tank El Tight Tank ® Other(describe): 4. Effluent Tee Filter present? El Yep o � If yes, was it cleaned? ® Yes ❑ No. S. Condition of System: /) ✓ 6. System Pumped By: Nell Batesbn F5821 Name Vehicle License Number Bateson Snte rises Inc Company 7. Locatio inhere contents were disposed: G-41 AHaule Lowell Waste Water 41 Sign Cate t5form4.doco 06/03 System Pumping Record®Page 1 of 1 Commonwealth of Massachusetts City/7own of System Pumping Record NOV .0 Form 4 DEP has provided this form for use by local Boards of Health. Other,forms�"may be used; buf 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, Leftfit rear of hou?�s, 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 State ,Zip Code 2. System Owner: Name Address(if different from location) CitylTawn State`p _�1. Zip Ca„de Telephone Number B. Pumping Record f/ 1. Date of Pumping 2. Quantity Pumped: ©ate 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. Locati w re contents were disposed; Ca S. Lowell Waste Water Sign t e Haute Date t5form4.doc•08/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts w w Mui waw City/Town of - stem Pumping Record 4 'C ' F ,4` Farm 4 MWN 00 N Ktt4NI OVE;a HEADM DrEPA 1'M NT DEP has provided this form for use by local Boards of Health. Other forms may a use , 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: 1.e�_front of house, right front of house, left side of house, right side of house, Left rear of houses, rlght rear of house,-side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: Name -. __ __........__ ....._____---------------__-- Address(if different from location) __..._.,._.....-...._-. City/Town State ..Zip( �pjCode Telephone Number B. Pumping Record -- 1. Date of Pumping 2. Quantity Pumped: _____._.__.___..__.___._-.. Date Lallans 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): __..__.__._ _......._.____m.._..._._.._.__....._._..__...._...._._..___...._.._.._a__..____._ 4. Effluent Tee Filter present? n Yes [ No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio of ystem: '� { & System Pumped By: Neil J. Bateson F5821 Name Vehicle license Number Bateson Enterprises Inc. Company— 7. Locati�where contents were disposed: CS ?H- e 1 aste f Signatureler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts Clty/Town of ' System Pumping Record Form 4 may` l ufl-M, ��"`�i"F)ARI`I��iEN11EI DEP has provided this form for use by local Boards of Health. Other for Y19 irina '156( 4,bbutth6— 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 sid ,.of-hous Right side of house, Left front of house, Right front of house, Left rear of hou Atigh-t rear of ho� . Left rear of building. Right rear of building. Address < 1WS City/Town State Zip Code 2, System Owner: Name Address(4 different from location) Cityrrown State/Ci Code L � ) �f 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:0t 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatti-ate- ere ontents were disposed: Lowell Waste Water Signature of Hauler Date t5form4.doo•06/03 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts g City/Town of RkFEIVED System Pumping Record Form 4 NOV 13 2008 DEP has provided this form for use by local Boards of Heal 11 0ther1oft�t -w'4&". e but the information must be substantially the same as that provide 4. _§/Vid-for , check withyour local Board of Health to determine the form they use. The System Pumping Re&-o--r-d-Wffi" st be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left fronkim left side of house. Right front, ig�treq , right si<oChous-e�) forms onthe computer,use —---—---- ------- only the tab key Address 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� Z19-Code R I-P9005 Telephone Number B. Pumping Record 1 Date of Pumping2. Quantity Pumped: Date Gallons 3. Type of system: Cesspool(s) 4a-Septic Tank Tight Tank Fj Other(describe): --------- --------------- 4. Effluent Tee Filter present? Yes 0:-N�o If yes, was it cleaned? Yes [] No 5. Condition of System: J2Q 6. System Pumped By: Neil Bateson F 5821 -------- Name Vehicle License Number Bateson En#erprises Inc Company 7. Location where contents were disposed: Q.L.S.D Lowell Waste Water iig4naure 4ofr -Date ------- t5form4,doc-06/03 System Pumping Record-Page 1 of 1 RECEEIVED '1"t" R E E7E]D Commonwealth of Massachusetts C IV DE ( '�(J'�1 City/Town of DEC 0 3 Z007 System Pumping Record )w TOWN OF NOR"TH ANDOVER C)ri, tN�l Form 4 HFALT�H 6EPARTMENT .................. 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- forms on the < _computer, use only the tab key Address to move your cursor-do not State Zip Code use the return Cityfrown key. 2. System Owner: C_'A Name Address(i6d-iffe4ritfromfocation) -dify—/Town State V Zip Code S Telephone Number B. Pumping Record 1. Date of Pumping -bate 2. Quantity Pumped: ballons 3. Type of system: El Cesspool(s) Q—S-6pfic Tank ❑ Tight Tank ❑ Other(describe): 0 4. Effluent Tee Filter present? F-1 Yes FlIf yes, was it cleaned? [:1 Yes El No & Condition o Syste7n- "'k 6. System Pu By: Name Vehicle License Number Company 7. Location when ontents were dip ed: Signature of Hau er Date t5form4,doc-06103 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts a� City/Town of I .' System Pumping Record Form 4 N 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 Important: When filling out 1. System Location: forms on the ._. `• v 1 computer,use only the tab key Address -- ' , -....— to move your rr c '4 J'` u-2' "" cursor-do not use the return City/Town State o key. 2. System Owner: Name - _......_ rern Address (if different from location) City/Town State ! < Zip Cade" Telephone Number B. Plumping Record r 1. Date,of Pumping Date 2. Quantity Pumped: __Gallons ........---__ 3. Type of system: ❑ Cesspool(s) Q eptic 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 Xped Name4kjVehicle)icense Number w Company 7, Location k6re contenwer aced: r^ Signa re o ler Date http://www.mass.gov/dep/wa er/approval8/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TOWN OF SYSTEM PUMPING R. 1 - DATE: F- NNol'i-TI 2�,0W 0D5 ,OWNtO W VTTE R SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) DATE OF PUMPING: QUANTITY PUMPED : GALLONS CESSPOOL: NO �'--�YES- SEPTIC TANK: NO YES NATURE OP'SERVICE: ROUTINE. EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASEBAFFLES IN PLACE ROOTS LEACHFIELD RUACK EXCESSIVE, SOLIDS FLOODED SOLIDS CARRYOVE R OTHER(E XPLAIN) sysum PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONniNTSTRANSFERREDTO: .L. 4G Lowell ante TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: e -, of house) exam t rout , A� l ��e. GALLONS DATE OF PUMPING: � :..M �UANTITY PUMPCD CESSPOOL: NO YESM SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: <=� COMMENTS: CONTENTS TRANSFERRED TO: Common weal(It of Massachusetts ave PyIp i n,g-Re cord System Owner System Location N; Dale of Cluahtity Pumped: gallons Cesspool: No C °�� Yes Septic Tank: No l._1 yes r]"M.... .... �� System Pumped by: varejea rt ict License # Contents transferrred to : Greater LawrenceSatiltary District Date: _ lrispector' Commonwealth orMassacliuset(s &,)O?,(IVUssachusclts _ystetm putn ire Reeord System Other System Location w Quaiitity Pumped: gallons Cesspool: No Yes Septic Taiik: No L] Yes System Primped by: velredars eoreow 4 License # Contents transferrred to : 94e81er wr�rice 8anttarY Utstrtct Date: ___ Inspector: n