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HomeMy WebLinkAboutSeptic Pumping Slip - 164 MILL ROAD 7/27/2017Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 oif011yrll:silMertlygdaRga. al 3 („) LL TOWN (II)F NORThi, ArCOVER DEP has provided this form for use by local Boards of Health. Other forms aripe-useaiatmine.,„.._,„1„„ 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 / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address 1,6 LE 1,,0 pek /De, 17.4k( City/Town State 2. System Owner: Zip Code Address (if different from location) City/Town Telephone Number B. Pumping Record Li( - 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: D„ Cesspool(s) E] Tight Tank El Other (describe): 4. Effluent Tee Filter present? 1:1 Yes 5. Condition f System: )0c If yes, was it cleaned? El Yes El No 6. System Pumped By: Neil Bateson 7, Name Bateson Enterprises Inc Company re contents were disposed: Lowell Waste Water Sign tu e Haule F5821 Vehicle License Number Datb—LR- (1' 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 used, but the information must be substantially the same as that pr is 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(ceft side ight side of house, Left front of house, Right front of house, Left rear of house, Ri§liffai. of house. Left rear of building. Right rear of building. Address t (tt City/Town 2. System Owner: SA—\C Name Address (if different from location) City/Town Telephone Number Zip Code B. Pumping Record 1. Date of Pumping 3. Type of system: D LI Other (describe): Date 2. Quantity Pumped: Cesspool(s) Ert-e-r)fic Tank LI Tight Tank 4. Effluent Tee Filter present? D Yes 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locati ry contents were disposed: L we aste Water L./1.,t.." If yes, was it cleaned? El Yes [1] No F5821 Vehicle License Number Signature o Ha ler Date fc) t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Important When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of System Pumping ecord 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 deterrnine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Infor 1. System Location: Address Clty/Town 2. System Owner: Name , ation Zip Code Address (if different from location) City/Town Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: Ej Other (describe): Date Cesspool(s) 2. Quantity Pumped: Gallons eptic Tank E Tight Tank 4. Effluent Tee Filter present? ID Yes Erl‘lo If yes, was it cleaned? ID Yes El No 5. Condition of ystem: ‘(, 02( Company 7. Location wheee QOfl osed: Vehicle License Number Signatur H I Date t5form4.doc. 06/03 System Pumping Record Page 1 of 1 DATE: OF SYSTE ( L.> DATE OF PUMPING: CESSPOOL: NO YES NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOL I S SOLIDS C YOVER CFVFfl CO MAR 2 2 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT (example: left front of house) 17 QUANTITY PUMPED : GALLONS SEPTIC TANK: NO YES SYSTEM PUMPED BY: atesou Enterprises COMMENTS: EMERGENCY n FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODE OTHER (EXPLAIN) 111 CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of 1 System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The S be submitted to the local Board of Health or other approving authori ust A. Facility Information 1. System Location: Address Cityfrown Address (if different from location) CityfTown State State e) Telephone Numbe Zip Code Zip Code' B. Pumping Record 1. Date. of Pumping Date 2. Quantity Pumped: 3. Type of system: LI Cesspool(s) E- epticTank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ©'" z n vtAe., 10/e c--(Z%L,Vt 5. Condition of System. System Pumped By; Name Company Locatil where tur of .'ler http://www.mass.govidep/ ate /approvals/t5forms.htm#inspect wire disposed: t5form4.doc• 06/03 If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Date System Pumping Record • Page 1 of 1 TOWN OF SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS LA Hot v(A.v\A_e_ 17'L( Mi SYSTEM LOCATION (example: left front of house) ( DATE OF PUMPING: CESSPOOL: NO YES QUANTITY PUMPED: NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SEPTIC TANK: NO EMERGENCY YES FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: GALLONS CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Conitnonwenith of Massachusetts Massachusetts stern P4!!i!!pin d System Owner System Location Date of Pumping: Quantity Pumped: lions Cesspool: No Et -ma-- Yes Ll Septic Tank: No LI System Pumped by: 64e6/00 ftPride4 Yes License I/ Contents ttanslettred to Greater Lawrenco sanitary [Astrid Date: Inspector: FORM? 4 - SYSTEM PUMPENG RECORD Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner W-ko CPS System Location /6, v Date of Pumping: Cesspool: Yes C System Pumped by: �"- Contents transferred to: C, Quantity Pumped: / $Tv gallons Septic Tank: No ❑ Yes License #: Date Inspector