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HomeMy WebLinkAboutSeptic Pumping Slip - 60 DEER MEADOW ROAD 1/10/2018 (2) ssachusetts Commonwealth of Ma mx City/Town of a System Pumping Record 2 .d 4 Form 4 ;O'WNi OF NOa),, DEP has provided this form for use�by local Boards of Health. Other for 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,dl /Righ rpra�'o ho , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/ building, Under deck Address 6 ' ' City/Town State Zip Code 2. System Owner; �r Name' `! Address(if different from location) City/Town State� ,r / Zip Code Telephone Number w t 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: V\1 6. System Pumped By; Nell.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location�here contents were disposed: L C S: Lowell Waste Water j 1 0 1 4ne Hauls Date t5form4.doc•06/03 System Pumping Record-Page 1 of 9 Commonwealth of Massachusetts u City/Town of rR I �' � " �� a"System Pumping RecordTOWN OF NOK[H ANDOVER Farm 4 l�l i� ��� -I'MENT 1 DEP has provided this form for use by local Boards of Health. Other forms may beused, 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 fora/they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1 1 System Location., /Rghfr /Lgh, e_rofourLefIrl h ei de6f house, Left lding,Right side of building, LeftRight front of buIgeft Right rear f building, Lin deck / Address r^ City/Town State Zip Code 2. System Owner: Name Address(if different from location) Code City/Town � atez..._,.� �H. � � � � ��Zip de vl Telephone Number B. Pumping Record 1. Date of Pumping ..w � ....... a 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) [l"'geptic Tank ❑ Tight Tank 0 Other(describe): 4. Effluent Tee Filter present? ❑ Yes ©''No If yes, was it cleaned? ❑ Yes ® No 5. Conditio o S stem: w L„ ..,.._. :, " .. 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company S 7. Location,.y!here contents were disposed: " Lowell Waste Water IaA SignAtufe 9t Haule Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 n wwrmmw m ww w.ww wren ow,r,rme°' Commonwealth of Massachusetts RECEIVED r City/Town of JUN System Pumping Record Form 4 , �,����u� i�-�p�"I E) n i u T ENT, �: 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/Right rear of house, Left/ t id of housb, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address r � Cityrrown/�f; State Zip Code 2. System Owner: 4 Name Address(if different from location) Cityrrown mm S '-7 cfip Code Telephone Number B. Pumping Record (6 �s k 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ❑'"§eptic Tank ❑ Tight Tank ❑ Other(describe): �a 4. Effluent Tee Filter present? F-1Yes ®-t1a If yes,was it cleaned? ❑ Yes ❑ No 5. Conditioof S stem: O 6. System Pumped By: _Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. L.5%iorr �er contents were disposed: G.L4eHaule Lowell Waste Water r 481gn9 Date t5form4.doc•06103 System Pumping Record•Page t of 9 -� Commonwealth of Massachusetts City/Town of -- p System Pumping Record A 4 ZU 11 Form.4 OVV� j1h DEP has provided this form for use by local Boards of Health. Oth rr4�9 � 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 1. System Location: Left front of house, right front of house, left side of house, Le lght side of house, ft rear of house, right rear.of house, left side of building, right rear of building, under e�C cR---""" - -- g g _ City/Town State Zip Code 2. System Owner: C) le4e Name Address(if different from location) -- __._ City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping — _..__..___.__...__..-_--.._...... 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) F�"Septic Tank ❑ Tight Tank ❑ Other(describe): --------- ---------- 4. Effluent Tee Filter present? [I Yes Ej-`rvo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System- - m� V\. +5�Uj—, _ & System Pumped By: Neil J. BatesonF5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location where contents were disposed: 3.L.Wauler ste ter ._ ......... Signa Date t5form4.doc•06103 System Pumping Record•Page 9 of 1 Commonwealth of Massachusetts x _ City/Town of KE w —_ System Pumping Record l ,. Form 4 ZI : DEP has provided this form for use by local Boards of Health. Other information must be substantially the same as that provided here. Beith 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 side of houCeeRight side ofhouse; Left front of house, Right front of house, 1 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) City/Town Stat Zip Code Teiephone Number B. Pumping Record —1 1. Date of Pumping - -- 2. Quantity Pumped: - k7ate Gallons i 3. Type of system: © Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes P-go If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: (A 6. System Pumped By: Neil BatesonF5821 Name _ Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L .. D Lowell Waste Water -------------- g toe of Haul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of I Commonwealth of Mhefts Important: City/Town of System Pumping Record RECEIVED Form 4 DEP has provided this form for use by local Boards of Health. Other orms#�*6,6 &AJU it J; information must be substantially the same as that provided here. B ore using this form, check ith your local Board of Health to determine the form they use. The System P mp rr mitted to the local Board of Health or other approving authority. HFALYH DEPARTMENT A. Facility Information " 1 8vmtenn [onmtion' [a��o ��� �ightfn)O� hQbtrem� hghtejd� nfh�x�� VVhenhU]nDou� � ' � // . ' . �nnaon�a L~__~~'� -----' computer,use only the tab key Address iomove your oumo/-do not City/Town State Zip Code use the return key. 2. System Owner: ` Name Address(if different from location) Cd�Town State Zip Code LD Telephone Number B. Pumping Record I. Date of Pumping -7 2. Quantity Pumped: Date Gallons 3. Type ofsystem: Cesspool(s) l0—��pti�Tmnk [1 Tight Tank F] Other(describe): 4. Effluent Tee Filter present? Yeo 0~ku |fyes,was itcleaned? Yen F7 No 5. Condition fSystem, 6. System Pumped By: Neil Bateson F 582 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: *.L.S.D Lowell Waste Water of r 1gna ure 4ofH u r Date t5fom4.dmc-06/03 System Pumping Record^Page 1ofi Commonwealth of Massachusetts City/Town of wm lY ,. w � System 1 r �, �. Form 4 w��..�L 00 � nrr� .rI(M- a DIP has provided this form for use by local Boards of Health. Othe toort $'mays u€se but t information must be substantially the same as that provided here. Bef6t6 using-this 1�cirim;cher 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 out1. SyStemio � �. )" .w forms on the s computer,use —------.- only the tab keyAddress to m move your CDe cursor-do not `- __._. use the return Cityylrown State Zip Cafe key. Z System Owner: ti uName ,ter Address(if different from location) 6i ylrown State ., Zip C e Telephone Number B. Pumping Record 1, Date of Pumping Date 2. Quantity Pumped: daiions 3. Type of system: © Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): - 4. Effluent Tee Filter present? ❑ Yes IVa If yes, Was it cleaned? ❑ Yes © No 5. Condition of System: 6. Syste Pumped By: Vehicle Name � License Number Company -_--_—_--- 7. Location ere contents w isposed: Signa t a ler Dake t5form4.doca 06103 System Pumping Record 4 Page 1 of 1 Commonwealth of Massachusetts ax City/Town of System Pumping Record Form 4 2,00 fl DEP has be submitted to he local Board of Health or otherdapprov nig authority.�fstwN -�t0lg�Stec rd must p y local r A. Facility Information Important: �t1017' he computer,forms on useC'N C ..- When tilling out ystem Y Y ---. and the tab key Address to mare our _ __ ✓ 'Y cursor-do not -_._. use th&return Cityfrown State ✓ Zip Cade key. 2. System Owner: H 0 Name Address(i(different from location) Cityfrown Stat - -. .�.,. �, r ,ode' Telephone Number B. Pumping Record 9. 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 ® o'-- If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pu peal By m Vehicle license Number Company 7. Locatio -where coritZ 7ernposed: b Sign ure uler Date http://www.mass.gov/dep/water/a pproval8lt5forms.htm#inspect t5form4.doc-06103 System'Pumping Record•Page 1 of 1 4� TOWN OF � SYSTEM PUMPING RECORD I DATE:_{ � UVED o V SYSTEM OWNER cos ADDRESS SYSTEM LOCATIO "E, � (example: left front of house) v C� al DATE OF PUMPING: QUANTITY PUMPED : )(J( GALL )NS CESSPOOL: NO YES _7SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELID RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CAIZRYOVER OTMR(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L. .D Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPINGCORD JOZ � 1 1 ENI OWNER & ADDRESS SYSTEM LOCA 110 N ( xmmple: left from r. c hou) ) M6 U E OF 11UM1)1NC; 1 _ QUANTI'-1'Y 1)UMPE1) CALL0',,) i ' S � r. )'1 (�( L; NO _ YES _ SCI. "r'((' TANK: NO L --- ATURE OF SERVICE': ROUTINE it EMI?RGENCY ___.__._____._ F�VA`h10NS, GOOD CONDITION _ FULL TO C:OVEIZ H F'A V Y CREASE 13 A F F I-E S IN P L A C`b' ROOTS _ LEACHFIELD RUNBACK _ EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OJ HEIZ (EXPLAIN) y I lr'M P U M P E D B Y: _ _� �: ���� 1 __-._-----__.___-----__... 7`I A N S 1I E I Z I I?I) `r'O: NORTH ANDOVER DATE CUSTOMER DESTINATION EST GALLONS 4/14/99 JUSINSPECT LOWELL 1500 i60 DEERMEADOW RD 1 i , TIN-KING ENTERPRISES, INC. .26 Uvin stop Street Lgwojj� MA-01852 f 199 Pagel , Commonwealth of Massachusetts Massachusetts j i ,I .steres Pumvina Record t System Owner System Location N .Date ofi�Pumping: Quantity Pumped: °' -"gallons Cesspool: Nom- Yes d Septic Tank; No Yes System Pumped by: 94&JOset License# Contents transferrred to : greater Lawrenge Ijanitary District Date; Inspector i