HomeMy WebLinkAboutSeptic Pumping Slip - 185 INGALLS STREET 8/2/2017Commonwealth of Massachusetts
City/Town of
ystem umpin - ecord
Form 4
I!
111111
1111!1,
TO\NIN NU( v-t. ANUOVER
HEALr11 DEPARTMENT
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 hltjYarit of houses Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right fr6ffbuiIding, Left / Right rear Of building, Under deck
State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
Pumping Record
1. Date of Pumping
3. Type of system: 0
0 Other (describe):
Date
State,f Zip Code
IL —ter? 447
Telephone Number
2. Quantity Pumped:
Gallons
Cesspool(s) 0 Septic Tank 0 Tight Tank
4. Effluent Tee Filter present? 0 Ye No If yes, was it cleaned? 0 Yes 0 No,
" 5. Condition System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatio jere contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
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Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
- 2.006
DEP has provided this form for use by local Boards,of Health.. The ,ystemPl".b:Ciriliiilrig R)'ef'cc)\\Or"--1'di-Must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
1. Syste Location.
Address ce"
City/Town
System Owner:
Name
State
Address (if different from ocation)
City/Town
State/
Telep one Number
?) Cede
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
3. Type of system: 0 Cesspool(s) Q.-Septic Tank
Other (describe):
4. Effluent Tee Filter present? Ell Yes [11-44
5. Condition of Sy em.
6. Systeti Pumped By:
Name
Company
Locatpq where contents were d" osed:
Signet e of
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
Gallons
[1] Tight Tank
If yes, was it cleaned? 0 Yes 0 No
Vehicle License Number
t5form4.doc• 06 03 SystemPumping Record Page 1 of 1
TOW OF ORTH ANDOVER
S ?STEM P UM PING RECO RD
^ )! r^r1 OWNER & ADDRESS
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OF
QUANTITY PUN1I'r.D
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YES
SEPTIC -YANK )
R E OFSERVI C.E ROUTINE 1..7 E ERCENCY
...HrkVATIONS:
COOD CONDITION
HEAVY CREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
LY1 PUMPED BY
ULL TO CO v
BAFFLLS IN I'L.,,\CL
LEAC 11 FIELD
FLOODED
0.4HER (EXPLAIN.)
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Commonwealth of Massachusetts
, Massachusetts
yam Pureeing Record
Date of Pumping: J ' tO ' ;0)-1)
System Location
Quantity Pumped: 1- gallons
Cesspool: No iY( Yes LI Septic Tank: No Li Yes rI.47
System Pumped by: 64redeo c,dret/tfti4ed License 11
Contents transferrred to : Greater Lawrence Sanitary Vistrict
Date: Inspector