HomeMy WebLinkAboutSeptic Pumping Slip - 111 CHRISTIAN WAY 12/14/2017 Commonwealth of Massachusetts
_ City/Town of .
System Pumping. Record
Form 4
DEP has provided this form far use¢by local Boards of Health, Other farms m�y4be i'US6 ��Au
the
information must be substantially the same as that provided here. Bef6�41`iing,this , check with your
local Board of Health to determine the form they use.The System Pumping i4ecord 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( fight rear of ho sk , Left/right side of pause, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address -
Ci#ylTown Sta a Zip Code
2. System Owner:
Name
Address(if different from location)
. City/Town � '. Stat �- �ide ;
Telephone Number
B. Pumping Record �..
1. Date of Pumpingnate 2. Qua City Pumped: Daltons
3. Type�of system: F1Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee f=ilter present? n Yep 0'40 If yes,was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Sys m:
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Locatiapn wt 7,re contents were disposed:
„C S: Lowell Waste Water
Sign a Houle Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
4 r City/Town of
System Pumping Record I ANDOVER
Form 4Ah
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 fight rear of house Xeft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State _ Zip Code
2. System Owner:
Name V
Address(if different from location)
City/Town State - de
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Lallans
3. Type of system: ❑ Cesspool(s) [1`Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condi on �f System: �f� J � �❑
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Location whey ontents were disposed:
GL S. Lowell Waste Water
—
Sign toe Haule4j Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
- W City/Town of
System Pumping Record
- , 6 Form.4
a xv�
DEP has provided this form for use by local Boards of Health. Other TMW
information must be substantially the same as that provided here, Be I 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 m-
1. System Location: front of house, right front of house, left side of house, right side of house, Left
rear of house. right r r of house, ft side of building, right rear of building, under deck. _
City/Town State Zp Code
2, System Owner:
-Name
Address(if different from location)
f _
State
Telephone Number
B. Pumping Record
�
1. Date of Pumping nate - —m 2. Quantity Pumped; Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑-lq-o f' If yes, was it cleaned? ❑ Yes ❑ No
5, Condition of yst)em
`✓ __ ___— ���-Chi`--�f-
& System Pumped By:
Neil J. Bateson F5821
N _
ame_ _.- _ Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
.L. Lowell ste ter
Signa u of auler _ Date
t5form4.doc•06103 System Pumping Record-Page 1 of 1
RECEIVED
Commonwealth of Massachusetts09
r. City/Town of ANDOVER
System Pumping Record m`rI41
.�si�AOWNUTH D �a L
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the 1
information must be substantially the same as that provided here. Before using this form, check with your
I
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: 1 System Location: Left front, left rear, left side of house. Right fro , right rear s' e of ho s
When filling out y
forms on the
computer, use
Address only the tab key Address
to move your )) ! ��-'�� . .`� \. -)C" Zi ' ��.k.,�w
I. ! � �a -_ _4.../`�..
cursor-do not City/Town
State P Code
use the return
key' 2. System Owner:
Name
Address(if different from location)
State Zip Code
Cityrrown
Telephone Number
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped: Canans ��
3. Type of system: Cesspool(s) -N eptic Tank ] Tight Tank
j Other(describe):
4. Effluent Tee Filter present? 0 Yes 0-40~ If yes, was it cleaned? El Yes [ No
5. Condition of System. ,
6. System Pumped By:
Neil BatesonF 5821 _
Name _ _ Vehicle License ber Num
_Baateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S. Lowell Waste Water
igna ure of H u r _ Date
t5fbrm4.doc•06103 System Pumping Record•Page 1 of 1
i
TOWN 0
J01
SYSTEM PUMPING RECORD
DATE: "
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of louse)
YAV v (2(:_
6me
1 l
DATE OF PUMPING: ( 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 LEACIIFIELD RUNBACK
I'
+,XCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTFIER(EXPLAIN)
I
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONM NTS TRANS + + D TO:
i
Commonwealth
of Massachusetts
City/Town of � JUL 5 20V
System Pumping rd ER,ec,,r,41 r
Form 4
DEP has provided this form for use by local Boards of Health. Cather 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
Important:
When filling out 1. System Location:
forms on the G `ilk ` r
computer,use
only the tab key Address
to move your
,.
cursor-do not -` State �- Zip Cade
use the return C�tyfrown
key. 2. System Owner:
VQ
Name
m Address(if different from location)
City[Town Statr-s ��ip e
Telephone Number
B. Pumping cor -. .
1. Date of Pumping bit-e— 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0— ep'act Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? El ,�Yes No If yes, was it cleaned? r-1 Yes El No
5. Conditio System:
6.. System P mp d By: E: u
-. �. .. Vehicle License Number
Name G�...a� � ,�e'k1'�._..
Company
7. Location whe nt nts we dis ed:
Signature of He
Bate
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Form 4 system Pumping Record
Commonwealth of Mossachusetss
Massachusetts
System Owner System Location
WA")"
jJ H,, "AY
H"I"no
Type; F y
Routine k"",
Cess i; Yes Septic tank: No Yes
bate of Pumping: Quantity Pumped; Gallons
system pumpeA By: WW River Envilvninental UC Permit#:
Contents transferred to:
Contents bisposed at:
1�!7............
Gate; Pumper Signature:
CorWition of System/Other Comment$
Dep Approved Froln - 1107195
.........
I�ORM 4-SYSTEM PUMPING RECORD
CURRIE
SEPTIC & DRAIN SERVICE
107 FORES'C STREET; MIDDLETON, MA 01949
(9785) 774-2772
COMMOI`,RVEAL'i'IT OF MASSACI-IUSE1"I,S
MASSACHUSETTS
SYSTEM OWNER: � - SYSTEM LOCA'T'ION:
zv
DATE OF PUMPING: ' �/ ! QUANTITY PUMPED:
j�' Jo GALLONS
ti
CESSPOOL: NO � Y E s � SEPTIC TANIC: NO Q YES
SYSTEM PLUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSI�`EIZI2ED rl"0:
DAPI:;:_ r �S' c�� � 1 INSPECTOR.: 4�r''/'1��
G
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