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HomeMy WebLinkAboutSeptic Pumping Slip - 197 VEST WAY 12/8/2017 Commonwealth of Massachusetts City/Town of ° w° Syrs' tem Pumping.Record Form 4 DEP has provided this form for use.by local Boards of Health. Other corms 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 Locatiot�L,:�M Righ ont of house Left/Right rear of house, Left/right side of house, Left Right side of bui Left/ ' t-fr-en uildirig, Left/Right rear of building, Under deck Address CWTown State Zip Code 2. System Owner. 1 Name Address(if different from location) Citylrown State ZiD Code0 � —a I ; Telephone Number r' s .B. Pumping Record 1. Date of Pumping Date 2. Quanti umped: Lallans 3. Type-of system: ❑ Cesspool(s) eptic Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes a if yes, was it cleaned? E] Yes ❑ No " 5. Condition of System:, 6: System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Lo here contents were disposed: C L Lowell Waste Water r SignAtu I Fe ct HWe Date t5formit.doc-06103 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts City/Town of . W System Pumping.Record Form 4 i DEP has provided this farm for use=by local Boards of Health. Other forms maVr 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 foram 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 Lehr Ig :t�tuildifig, e, Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/ Left/Right rear of building, Under deck Address Cityrrown } State Zip Code 2. System Owner: Name' Address(if different from location) Citylrown - State ode 'telephone Number s d d B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons ` 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No, ' S. Condition of Sy tem: i 6: System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Ehterprises Inc- Company 7. Locatl here contents-were disposed: GISR Lowell Waste Water 4 SlgnVt4e 9 Haute Date t5form4.doc•06103 System Pumping record•Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for usezby 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 C6 ' Rig ;ho:q34, Left/Right' rear of.house, Left/right side of house, Left/ 1. System Locatio, n'of t of t Right side of butOga.YL eft Right fron of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner: Name' Address(if different from location) City/Town State ( Cl-Zip o Code Telephone Number B. Pumping Record �Zl 1. Date of Pumping Date 2. �Quan ity Pumped: Gallons pr ;� ic Te 3. Type of system-. ❑ Cesspool(s) eptic Tank M Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? E] Yes 0--N-o If Yes, was it cleaned? E] Yes F1 No, ' 5. Condition of System: 6. System Pumped By: Nell Bateson F5821 -Name Vehicle License Number Bateson Enterprises Inc, Company 7. Location-wher contents were disposed: L S. Lowell Waste Water Sign Atufa IHaute Date t5form4.doc-06/03 System Pumping Record•Page 1 of 9 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Othef 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 Locatihouse Left/Right rear of house, Left./right side of house, Left o J�1"' Righ6frqnt of Right side of buzrc6g, Left Right front of-66ilding, Left/Right rear of building, Under deck Address City/Town state Zip Code 2. System Owner: Name Address r'REQE1VE5-­1 City/Town state/—>-, Zip Code HAY 2 �3 Z013 Telephone Number TOWN Uf-�140RTH ANM)VER D�llil�,'Ak"i,*I-lll')EFIAP,'IMEI,4T 1, M........................ -- B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: El .Gesspool(s) 0`Sepfic Tank M Tight Tank ❑ Other(describe): 4. Effluent Tee I Filter present? E] Yes EIIN�o If yes, was it cleaned? ❑ Yes F-1 No 5. Con?',nitem: System: , 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company . 7. L o c.:att i mere contents were disposed: Lowell Waste Water I Sign toe qf HauleV Date t5form4.doc-06103 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts City/Town ofi . n System Pumping Record Form 4 L—RERC 01? N R i"t AND VER DEP has provided this form'for use by local Boards of Health. Oth - he 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 Locatio . Le Rig runt of ho sue eft/Right rear of house, Left/right side of house, Left/ Right side of buil Ing, Left/Righ ran of ullding, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cityrrown Stat .Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio of ysteM: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca ' er contents were disposed: G.L S. 1 Lowell Waste Water Sign toe I Haule Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 4N- -- Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record tji Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Oth ay e use , u the information must be substantially the same as that provided here. Before using this 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: Left side of house, Right side of houso,'_Left front of tTu§p ,Rj6ht front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address City/Town State Zip Code 2. System Owner: Name ......------- Address(if different from location) ..... ........... Cityrrown State . Zi Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quaoty Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ff-Septic Tank El Tight Tank El Other(describe): ............... ...... 4, Effluent Tee Filter present? 0 Yes E]-INo If yes, was it cleaned? E] Yes 0 No 5. Condition of System: /Cl 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location wh�r.e contents were disposed: G.L S.b. Lowell to�te Wat�er -S ------ r .......................................... f Sig-nature f n Mal�e r Date t t5form4.doc-06103 System Pumping Record-Page 1 of 9 _ Commonwealth of Massachusetts RECEIVE _a City/Town of N :15 " System Pumping Record ����������� � Form 4 TOWN F NO jai/04)()`�[.R . HEAA T D I a Li�I 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 farm, 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 _um_ Important: ^� When filling out 1. System LacakiC} Le fr , left rear, le of house. Right front, right rear, right side of house. forms on the `� __ _.___,._.._....._.. computer,use only the tab key Address to move your cursor-do not -- use the return City/Town State Zip Code key. - 2. System Owner: F-c:) Name ------ �_ - -- --_---------- Address(if different from location) - City/Town Stat � Zip Code �...__ I C✓ Telephone Number B. Pumping Record o 1. Date of Pumping te --- 2. Quantity Pumped: Date Gallons 3. Type of system: Cesspoal(s) eS pt Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? Yes o If yes,was it cleaned? Ll Yes No 5. Condition of System: V\- 4eC4_,Ck 6. System Pumped By: Neil Bateson - F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio ere contents were disposed: L.S.D Lowell Waste Water - _-,_r - igna ure of H u r Date t5form4,doca 06103 System Pumping Record-Page 1 of 1 4 Commonwealth of Massachusetts City/Town of � 2' System Pumping Record Farm 4 A � CEP hasy rovided this form for use by local Boards of Health. Other forms may be used "f >ee,aM f � , 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. f A. Facility Information When filling nutY �. 1. S ste �Loc t on forms on the computer, use a tab key Address +� e- tomo to move your .. _ cursor-do not -�-_..Cit. ( A'ate Zip Code use the return y/'rown key. 2. System Owner: .. ...-. 10 Name ,n Address(if different from location) _. _..._ '" i Code City/Tawn Stat ._:_... �'�� '�_. (,""�p. .m ( A2 Telephone Number B. Pumping Record [term 1. Date of Pumping — ___ 2. quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Cr Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ET"Wo7 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Syste P m By: �^ - Vehicle License Number Name Company ?. Locationre contenwer e posed: . .- C Signature ofa er [late t5form4.doc>06/03 System Pumping Record.Page 1 of 1 I I Commonwealths of Massachusetts A City/Town ofAPR, 12 5 2006 I .' System Pumping Record Form4 uOvVIir�f �� OaCl� /)J,l,r:'/H�l. 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 Information Important: fWhen orms on the out 1. S tem Location . 4 „ p g y .µ _. . computer, use onlythe tab key Address, Y _ :, _.._. to move your cursor-do not use thereturn City/Town State Zip Code_._..........—_ _. �� key. 2. System Owner: Name _. Address(if different from location) City/Town Stat Zip Code l .S Telephone Number B. Pumping Record U-171 1. Date.of Pumping nate 2. Quantity Pumped: .- ._.... ,...._ Gallons 3. Type of system: [] Cesspool(s) eptic Tank.. ❑ Tight Tank ❑ Other(describe): __.__...___ _ 4. Effluent Tee Filter present? ❑ Yes """ .. If yes, was it cleaned? ❑ Yes ® No 5. Condition of S stent: V\Oi �Llka_k [C"'Llok V\,�_I(e_17"L,"Lj 6. System Pulped By; Name � � Vehicle License Number Company 7. Locat' where corlten#s we r disposed: µ . Sig afu f aider Date http://www.mass.gov/dep/ ater/approvai8/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: L;," C' .. SYSTEM OWNER &ADDRESS SYSTEM LOCATION b (example: left front of house) wa W/''gyp _ -... kw\",C- -%3 DATE OF PUMPING: (a~fib - QUANTITY PUMPED GALLONS CESSPOOL: 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) SYSTEM PUMPED BY: , COMMENTS: CONTENTS TRANSFERRED TO: "