HomeMy WebLinkAboutSeptic Pumping Slip - 2198 TURNPIKE STREET 8/2/2017Commonwealth 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
1. System Location: Left / Right front of house / Righ ius, 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
2. System Owner:
'-t-A-(\
Zip Code
State
")( Ci\i•c)
Name
Address (if different from location)
City/Town
B. Pumping Record tx
1. Date of Pumping
3. Type of system:
E] Other (describe):
Date
Cesspool(s)
2. Quantity Pumped:
1/41 rfie
Gallons
El-ter:41c TankD Tight Tank
4. Effluent Tee Filter present? 1:1 Yes a'arl
" 5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7, Lo o ere contents were disposed:
Lowell Waste Water
If yes, was it cleaned? D Yes fl No
F5821
Vehicle License Number
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 No Andover
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System ocation:
0 -->t-
(
Address
No Andover
CityfTown
2, System Owner:
Name
Address (if different from location)
CityfTown
Ma
State
01845
Zip Code
N ?Ur?,
TOWN OF: '40FV1I1 ANDOVER
DE/ATMIENT
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date
2. Quantity Pumped:
/ 6
Gallons
3. Type of system: Ei Cesspool(s) 1E1' Septic Tank III Tight Tank [1] Grease Trap
LI Other (describe):
4. Effluent Tee Filter present? Ej Yes El No If yes, was it cleaned? E] Yes 111 No
5. Condition of System:
6. System Pumped B
Name
Stewart's Septic Service
Vehicle License Number
Company
7, Location where contents were disposed:
Stew eatment Plant, 20 So. Mill Bradford, Ma 01835
Signe f Receiving Facility
t5form4.doc• 03/06
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record
Form 4
JUL 18 all
TOWN OF NORTH ANDOVER
HEALTH 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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. Systetp Locotion:
forms on the computer, use rn
only the tab key Address
to move your No,Andover
cursor - do not
use the return City/Town
key.
L.
2. System Owner:
0
Name
Address (if different from location)
City/Town
Ma
State
01845
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Type of system: Cesspool(s) Septic Tank El Tight Tank E1 Grease Trap
Other (describe):
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? El Yes El No
5. Condition of System:
6. Pumped B :
Ce Crn
Stewart's Septic Service
Company
7. Location where contents were disposed:
ewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
LoJ'IL
Date
Vehicle License Number
il
Signature of Rece n ity Date
t5form4,doc• 03/06 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
E :D
AUG I I 2009
ANN OF NOIRTH ANDOVER
DEP has provided this form for use by local Boards of Healt .44-aia4Larilry-ULS0 , 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. Syste -Loc-ati n: Left side of house, Right side of house, Left front of house, Right front of house,
rear of hoU e, .ght rear of house.
Address
CityfTown
2. System Owner:
State
C
Zip Code
Name
Address (if different from location)
CitylTown
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: El Cesspool(s) Ei--Ser:tic Tank
El Other (describe):
Y71-1
>i 2. Quantity Pumped:
Gallons
El Tight Tank
4. Effluent Tee Filter present? E) Yes 0110 If yes, was it cleaned? El Yes 1111 No
5. Condit' n of Syst m:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Loc- n where contents were disposed:
.D Lowell Waste Water
irab
;
10,S,
Vehicle License Number F5821
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
,i,•01'get '
SYSTEM 0
(-5(W(iii2c)
c / 9
/14 ,rd,fry/zi/A.J
DATE OF PUMP1NQ:
TOWN OF NORTH ANDOVER
SYSTEM PUMP1NQ RECORD
c'ESSPOOL; NO YES,.
i•40 ruin OF SERVICE: ROUTINE_
ObSERVATIONS:
000D CONDITION
HEAVY OREASE
ROOT"
EXCESSIVE SOLIDS
SOLID CARRYOVER__
)(STEM LOCA
,
QUANTITY
PUMPED:
Septic Tank: NO,
EMER(JENC'Y
FULL To COVER
BAFFLES IN PLACE:,
LEACHFIELD RUNBACK
„ FLOODED
_ OTHER EXPLAIN
RECEIVED
MAR - 2 2005
'N OF NORTH A.NDOVER
EALTH DEPARTMENT
YES
sYstm PurnPfd b.A.1/66,t,tZr,.715 hs Sgrotce.)
it2i/ (513 Zgrao4az7, /r7a
c'UMMENTS.
L:ON VENTS rKANSFRRED l'U
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
ystem Pumping ecord
Form 4
'ff
DEP has provided this form for use by local Boards of Health. Other forms may be used,
information must be substantially the same as that provided here. Before using this forrn,
local Board of Health to determine the form they use. The System Pumping Record must
the local Board of Health or other approving authority.
but the
check with your
be submitted to
A. Facility Information
1. System Location:
t‘cSs
City/Town
Address
2. System Owner:
Name
Address (if different from location)
City/Town
Th
State Zip Code
State
c-5-S
Telephone Number
Zip Code
Pumping Record
1. Date of Pumping
3. Type of system:
Other (describe):
Date
2. Quantity Pumped:
Cesspool(s) Ell-Wtic Tank
Gallons
Ei Tight Tank
4. Effluent Tee Filter present? D Yes a -go If yes, was it cleaned? ri Yes Ei No
5. Condition of System: cci jaic
Company
7. Location wh cont nts were dis
VehicleLicense License Number
Date
t5form4.doc• 06/03 System Pumping Record Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
SYSTEM OWNER & ADDRESS
ATE OF PUMPING:
: NO C„,-r'" YES
SYSTEM LOCATION
(example: left front of house)
QUANTITY PUMPED
NATURE OF SERVICE: ROUTINE
SERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
GALLONS
SEPTIC TANK: NO YES
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHI+'IELD RUNBACK
FLOODED
OTHER (EXPLAIN)