HomeMy WebLinkAboutSeptic Pumping Slip - 327 SALEM STREET 7/20/2017 Commonwealth of Massachusetts . a
City/Town ®f
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/Right rear of house, Left/ h s de of h suo e�)Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Uride� c`k"
Address
CityfTown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown ' State Zip Code
F
Telephone�berms�� �-�._�•�-` ,�,',°
s ;
B.
Pumping Record
1. Date of Pumping crate 2. Quantity Pumped: Gallons
3. Type of system. El Cesspool(s) �tc Tank Tight Tank
® Other(describe):
4. Effluent Tee Filter present? El Yep o If yes, was it cleaned? Ej Yes ® No.
5. Condition of tem:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locaf where contents were disposed:
a Lowell Waste Water
Sign9tufe Haule Date
t5form4.doca 06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts � � �
- ti = City/Town of
System Pumping Record
Form 4
4 A vYNywa G VVfj C t t i�H9 t tR ANDOVER
C t.t�t
L. f°O PARJI41t:"N � �
DEP has provided this form for use by local Boards of Health. Ot w�6-rnay'�'b fid;Vut the
information must be substantially the same as that provided here. Before using this for 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 of house, right front of house, left side of hous@,�ight side of house eft
rear of house, right rear of house, left 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 Zi Code
Telephone Number
B. Pumping Record -
1. Date of Pumping - -- 2. Quantity Pumped: G
Date allons
3. Type of system: ❑ Cesspool(s) ❑ 'tic Tank ❑ Tight Tank
❑ Other(describe): _ ------------- —.___.___......__._._... ______..._
4. Effluent Tee Filter present? ❑ Yes [1–N -� If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Syst m:
IT
6. System Pumped By:
Neil J. Bateson F5821_
Name vehicle License Number
Bateson Enterprises Inc.
Company _
7. Lac inn where contents were disposed:
G.L.S.D. Waste ater
L�
Signature 10 dY Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
CityfTown of
-- System Pumping Record DEC . 5 Z009
Form 4 TOWN OF`HEALTNORfTH ANDO E
DEP has provided this form for use by local Boards of Health. Oth 'r°1orms-may°°b d-,'W1 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 of other approving authority.
A. Facility Information
1. System Location: Left side of h s'e'Rig.. _._....
Ight side otou� Left front of house, Right front of house,
Left rear of house, Right rear of house. ett rear of building. Right rear of building.
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State a ) ^ 7j Code
Mw �'
--- --------.
Telephone Number
B. Pumping Record p
1. Date of Pumping -- Galll- 2. Quantity Pumped: a-l --_.___. _._ .. ...
Da 11 ons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2-Nb If yes, was it cleaned? ❑ Yes ❑ No
5. ConditioU Or Systerr,
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L Lowell Waste Water
Signature of Hauler Date
t5form4.doc-08103 System Pumping Record•Page 1 of 1
i
I
Commonwealth of Massachusetts ... ��
it Town of t6 2008
System lug
Pumping cr
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 Location:, _
forms on the \ ✓ "" _
computer,use
only the tab key Address `
to move your
cursor-do not
Citylfowm State Zip Code
use the return
key. 2. System Owner: -,j� v�
Name
Address(if different from location)
Zip Code --
State
City/Town
Telephone Number
B. Pumping ec rd C
1. Date of Pumping Date . Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑-optic Tank ❑ Tight Tank
❑ Other(describe): --
4. Effluent Tee Filter present? ElYes 9--No If yes, was it cleaned? ❑ Yes El No
5. Condition of System: ` q
6. System Pyimped.By: �-
Name vehicle License Number
Company
7. Location where conte ttis wer spaced:
Signatur a — Date
t5form4.doc^06103 System Pumping Record^Page 1 of 1
<t'\ 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
Important:
When filling out 1. System Location:
farms on the C'
computer, use
only the tab key
to move your
cursor-do not
use the return CityrFown St --Z--i-p--Code
key. 2. System Owner:
t �4 V
VQ
Name
rein Address�(if differentfrom loc�
yffo'�.n- Stat-j., Code
Telephone Number
B. Pumping Record
1. Date of Pumping
2. Quantity Pumped:
Date Gallons
3. Type of system: Ej Cesspool(s) R-9Tank El Tight Tank
F1 Other(describe):
4. Effluent Tee Filter present? El Yes p-bio If yes,was it cleaned? [:1 Yes Ej No
5. Condition of Syst m:
6. Syste P roped By:
Name Vehicle License Number
::V\
Company
7. Locationere conte wernosed:
6n e Date
Page 1 of I
t5form4.doc-06/03 System Pumping Record•
Commonwealth of Massachusetts
City/Town of t
System Pumping Record
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 lnformation
Important:
When filling out 1. System Location:
forms on theuck
computer,use
only the tab key Address
to move your ? ti ° t fir;
cursor-do not
use the°return City/Town State Zip Code
key. 2. System Owner:
Name R WE U......._.
Address(if different from location)
Jul"', 1.x;
CityfTown State ()MIJ OF I40f"e FH Ak jO)QOOe
�� II
F
Telephone Number
.B, pumping Record
1. Date of Pumping .......... _ 2. Quantity Pumped: _...,. _�..._—
Pate Gallons
3. Type of system: � Cesspool(s) ❑8ept_
ic Tank U Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [3—Vf o If yes, was it cleaned? ❑ Yes 0 No
5. Condition of System:
6. SysteoPu� mped By 7�
� L C h
Name
t Vehicle License Number —_..
Company
.7. Locationwherecontents were disposed:
Sign tur of auler Date
http://www.mass.gov/dep/waterlapprovalt/t5forms.htm#inspect
t5form4.doc-06103 System'pumping Record•Page 1 of S
TOWN OF
SYSTEM PUMPING ECO
DATE: VIE p
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
6os-c-
DATE
OF PUMPING: �� .�`�w �°� QUANTITY PUMPED : 1 o GALLONS
CCSSP®ISL.
+ : NO YES 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)
I
sysTE,m PUMPED BY: utas®II Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.Dj Lowell Wast
i
TOWN OF
SYSTEM C
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
r ��i .�'�, (example:legit front of house)
l CC; l
DATE OF PUMPING: QUANTITY PUMPED : GALLONS
mow.
CESSPOOL: NO r.- YES 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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS T12ANSFEIiIiCD TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
kou
DATE OF PUMPING:
QUANTITY PUMPED I GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE —ZEMERGENCY
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: (-�7, Z,
Commonwealth of Massachusetts
Umsacligsells
System Pumpigg Record
System Owner System Location
/t
Date of 1111111ping: k) Quafitity Pumped: gallons
Cesspool: No Yes Septic Tniik: No yes [-4—
System Pumped by: Farejea rt BMW License #
Contents timisreuredto : Greater Lawreeico Sa"lta( Istrl It
-it V-
DaW Inspector-
FORM 4- SYSTEM PUNWIENG RECORD
Comtnonwealth of Massachusetts
Massachusetts
Svstertt Pumping Record
Sy
stem ��perSystem Location
V\, -
Date of Pumping: �`� Quantity Pumped: gallons
Cesspool: o Yes ❑ Septic Tank: No ❑ Yes -
A_ 1
System Pumped by- License #:
Contents transferred to:
i
Date Inspector
p