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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