HomeMy WebLinkAboutSeptic Pumping Slip - 970 JOHNSON STREET 12/8/2017 Commonwealth of Massachusetts
City/Town of .
System Pumping.Record �"���° CE a
Form 4
• jj. .. ab ?[, I
DEP has provided this form for us&by local Boards of Health. Other forms may abaused,,but the
Information-must be substantially the same as that provided here. Beforol,using;thlS fotrrii(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
I. System Location: Left/Right front of house, Left x ear of haus , Left/right side of house, Left/
Right side of building, Left/Right front of building, Leff/Right rear of building, Under deck
Address
• 1 p'Y mow„ 4,
City/Town l State Zip Code
2. System Owner. t
Name'
Address(if different from location)
City/Town _ State� - Zip Code ;
Telephone Number
B. Pumping Record
1. Date of Pumping date 2. Quantity Pumped: 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,
5. Condition of System.
AJOwLm - t v .
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loc4tion re contents were disposed:
G
�- Lowell Waste Water
'SIgnJqe fHaule Date
t5form4.doe-06/03 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts
City/Town of
a M° System Pumping Record
Form 4
DI=P has provided this form for us&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, Le Fight rear of housed eft/right side of house, Left/
Right side of building, Left/Right front of building, l gfi rear of building, Under deck
Addressv
Citylrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State `� � Zip Cgde
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
,A
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.
5. Condition of Systj� : f
6. System Pumped By: ( VE'
Neil Bateson F5821
Name Vehicle License Numbe MAY 77 71114
Bateson Enterprises Inc
Company "t() I OF'Iq Iii .IOIDOGE
7. Loc-atn-W contents were disposed:
Ca S. Lowell Waste Water
SignAtufe 9t Haule Date
t5form4.doc+06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
a Form 4
j
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 kj�i rear of hou`s ,Left J right side of house, Left J
Right side of building, Left J Right front of building, Left J Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner: l
Name' ':
Address(iffferent from location)
as r 0 Q.
City/Towntate Zip Co e
u�
�qC)p,,TH ANDOVER
t
'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 0"fro If yes, was it cleaned? p Yes ❑ No.
5. Condition f System: «... ���
6. System Pumped By:
Neil Bateson F5821
Name vehicle License Number
Bateson Enterprises Inc
Company
7. Locati here contents were disposed:
G.( Lowell Waste Water
Slgn toe Haute Date
t5form4.doc*0eia3 System Pumping Record•Page 1 of t
Commonwealth of Massachusetts
City/Town of �Q
System Pumping Record
Form 4 JUN
IOWN Ipra'0� IT
hm
R
DEP has provided this form'for use by local Boards of Health. Other form m� �bapv� e.��` �7' -
information must be substantially the same as that provided here. Before using'ks' �6t your j
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, Le Ripht rear, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 1-7
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ._ State �..�_ � � � ,dip Code
TelephoneNumber
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. Candiio N 7Zak �a"(J2'L � '✓� � �
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enter rises Inc
I
Company
7. Locat` - w i re contents were disposed:
G.LtS. 1 Lowell Waste Water
Sign toe 4 Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts ❑�EEEIVED
City/Town of
System Pumping RecordK' —,%)VER
TOWN OFN �0
Form 4 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.
A. Facility Information
1. System Location: Left front-,of-house, right front of house, left side of house, right side of house, Left
rear of house,fight'rear of ho6s��left side of building, right rear of building, under deck.
-70 ❑❑ ❑ � - � - � l❑
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
-—---------------
Zifyif ow;n Statqn c Zln;Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) a-Septic Tank ❑ Tight Tank
[I Other(describe):
4. Effluent Tee Filter present? 0 Yes 0'-N-o If yes, was it cleaned? F] Yes El No
5. ConU'fion,* f Sj!te( C �❑ ❑
m:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
P. --------......
Company
7. Lo atiaie here contents were disposed:
LA
G.L.S.ID A ellWaOe ter
Signatu o ler Date
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
s City/Town of
�� `System Pumping Record
TOWNNORTH
RH ANDOVER�
Farm 4 LhG HE
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 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 ,at' n: Left side of house, Right side of house, Left front of house, Right front of house,
Lift rear-of-hou 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)
-.._r...... _ _..... .... _,.
City£rown
Telephone Number
B. Pumping Record
1. Date of Pumping -- - 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) B Teptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Conditign of System:
01— 40:7VQ�-�
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locat, R-W'7ri contents were disposed:
G.L.S, 4 L well aste Water
Signature o I r Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record MAY 2 6 Z009
e Form 4
DE A Wi
y �a iv�l�bl����t�ta€��xTDEP has provided this form for use b focal Boards of Health. Other fo[�HEWTH
may' 96a "iu-th`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 or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left front�jk rear,eft side of house. Right front, right rear, right side of house.
forms on the
computer, useonly the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
4
"`<L
Mame
Address(if different from location)
Citylrown State Zip Code
Telephone Number
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? Yes 0- �o If yes, was it cleaned? Yes No
5. Condition of System:
c.
6. System Pumped By:
Neil BatesonF 5821
Name _ Vehicle License Number _._..
Bateson Enterprises Inc
Company��__
7. Location where contents were disposed:
L.S.D Lowell Waste Water
igna ure Zof Pr Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
.0 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.
RE 11EAVE
A. Facility Information MAY 0 5 2008
Important:
When filling out 1 System Locatipn- 1�.-) IF 1-H AN�X-)'/ER
forms on the �J�' t
DE�''AR ME!4 F—
computer,use
only the tab key
V
to move your
cursor-do not -City/Town Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
Cityfrown Stta�te�— Zip Code
-Telephone Number—'—
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
nate Gallons
3. Type of system: El Cesspool(s) [3-eeptic Tank El Tight Tank
M Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? F Yes R No
5. Condition of System:
KV)
6. Systemnum By:
k7n
I Vehicle License Number
,A
Company
7. Locationwr contents w e Tspp sed:
C
.. .........
Signature a Date
t5fon,n4.doc-06103 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
- City/Town of 1
2 4 2006
System Pumping Record r.
Form 4 TOWN OF NORTH ANDOVER
rcti r HEALTH DEPARTMENT
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:
When filling out 1. System L ation:
forms on the
computer,use _ -... . __
only the tab key Address
to move your .. �� �1 �'• l �� "
Cursor-do not _.,_._..�..._.. . __,.,__....— _...,..__ ,,_._. .,,_. ...,_._.._...._.._ ...
use the�return CitylTown State Zip Code
key. 2. System Owner:
4
Name
_.. m_..____: _._......
Address(if different from location)
CitylTown State , dip CodeCI—
Telephone Number _
B. Pumping Record
1. Date of Pumpingoate.....- 2. Quantity Bumped: __.....
Gallons
3. Type of system: (] Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): _... _
4. Effluent Tee f=ilter present? ❑ Yes b If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Systemmped Ry; - -
.n
M,n
Name Vehicle 1-icense Number
Company
.7. Location yifte coptents p,rr di ed:
SignatorWHal Date
http://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1
TOWN OF
DATE:
1
ire
j
i
1
1
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
Y
DATE OF PUIVIPIhIC: � 4 f�UANTITY PU ED : GALLON'S
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OT 'R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inca
COMMENTS:
CONTENTS TRANSFERRED TO: .L. . Lowell Waste
i
l -
TOWN OF
SYSTEMPUMPIN RECORD,--.-0
DATE:
OCT 19 2004
6['i I `�v i��'Ab,, ...
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of Lowe)
,ED . G
( - / ALLONS
DATE or PUMPING: QUANTIT V PUMP
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE. ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER.
HEAVY GREASE BAFFLES IN PLACE _ —
ROOTS LEACHFFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED To: O.L. .1) Lowell Waste