HomeMy WebLinkAboutMiscellaneous - 24 FARNUM STREET 4/30/2018 (2)Commonwealth of Massachusetts RECEIVED
City/Town of .
System Pumping. Record JUL b 201
Form 4 TOV4N OF HCF�tiH At+1DG5Q��R
HEALTH DEPARTMENT
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 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 housight of hous Left/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, er d
. Address
City/Town State Zip Code
2. System Owner. C4
Name'
Address Cd different from location)
Cityirown
B. Pumping
1. Date of Pumping
3. Type of system. ❑
4.
StWV a 3—�5_:SM13code
Telephone Number i
_C )9
Date 2. Quantity Pumped: Gallons
Cesspool(s) 3 -Septic Tank ❑ Tight Tank
❑ Other (describe):
Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6.. System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc -
Company
7. Locati'Ir.contents- were disposed:
O-� Lowell Waste Water
F5821
Vehicle License Number
Data
_Z�9 -6s-
t5form4.doc- 06/03 System Pumping Record • Page 1 of 1
1\ Commonwealth 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, Left/ Right rear of house, Left/ right side of house, Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
Cityrrown ' state Zip Code
2. System Owner.
Name
Address (if different from location)
Citylrown
B. Pumping Record
1. Date of Pumping
State t -7.
t4 Zig Code
Telephone Number
-�7 -)
Date 2. Quantity Pumped:
3. Type of system. ❑ Cesspool(s) eptic Tank
4.
❑ Other (describe):
Effluent Tee Filter present? ❑ Yes LT No
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No:
5. Conditio iTt - -elk� V\:
6. System Pumped By.-
Nell.
y:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Locatio ere contents were disposed:
S. Lowell Waste Water
rJ —I
M
F5821
Vehicle License Number
/`( -�-
Data
t5form4.doc- 06/03 system Pumping Record • Page 1 of 1
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6zCommonwealth of Massachusetts
Executive Office of Environmental Affairs.
Department of
Environmental Protection
William F. Weld
Governor
Trudy toxe
Secretary, EDEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 4`1'W- AN ley vim- Address of Owner:
Date of Inspection: j,'? - N 4e (If different)
Name of Inspector: 54pti �3'(.Ty
Company Name, Address and Telephone Number:
A,1;7/�
'}`�`% 0 ✓ �✓ 5.911 T i.. G. /7j 1% ,4 li. /w/.�/3 1 � /90-1/( -`1.4
CERTIFICATION STATEMENT
''
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
S Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: /-2, Ll I �'C
The System Inspector,. all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing dais
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D: `-N
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES: 1 /
One or more system components need to be replaced or repaired, The system, upon completion of the replacement or repair,
passes inspection,
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
1
One Winter Street a Boston, Massachusetts 02108 a FAX (617) MG -1049 • Telephone (617) 282 -UN
Printed on RecjKkd Paper
\n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 02 `7 !' 44 V wt S r 1JL -t t70 v`
Owner: f}4
Date of Inspection: /1„ y_ d
B] SYSTEM CONDITIONALLY PASSES (continued) R4.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM�IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: I _,
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank.and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D] SYSTEM FAILS: P#
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
` for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
_ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due town overloaded or clogged SAS or
cesspool.
%I
(revised 8/15/95) .2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICAT ON (continued)
Property Address: :�.V
Owner:'
Date of Inspection:
D] SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool..
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary, to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for,
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
fl—
Thejollowing criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
R
(revised 8/15/95) 3
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: p C f a q
Date of Inspection: {
Check if the following have been done:
_L/Pumping information was requested of the owner, occupant, and Board of Health.
= None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
&A As built plans have been obtained and examined. Note if they are not available with N/A.
"/The facility or dwelling was inspected for signs of sewage back-up.
'The system does not receive non -sanitary or industrial waste flow
-/'The site was inspected for signs of breakout.
/All system components, excluding the Soil Absorption System, have been located. on the site.
J
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
/tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
J The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non -intrusive methods.
—The facility o•,%ner (and occupants, if different from owner) were provided with information on .the proper maintenance of Sub -
Surface Disposal System.
;}` . ,. .�--}-..e..�.r.-..�..a�.. _.y _ .. _ __. -.._ , _ _�, _y,�r..�- . .e .w.-�tr.�. .,v.+r'+rw�:.r„>...:y..Y �i•... + :.i. .. am+, -r .... � �:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�
c^ SYSTEM INFORMATION
Property Address: C 'jT�� u a f�G` !T"M QU v -0 -
Owner: -0-Ownerr
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ¢alto s
Number of bedrooms,
Number of current residents:
Garbage grinder (yes or no):�k
Laundry connected to system/(yes or no):10
Seasonal use (yes or no): tk
Water meter readings, if available:
Last date of occupancy:
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow: rtallons/day
Grease trap present: (yes or no) .
Industrial Waste Holding Tank present: (yes or no)_
Non -sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe) _
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped i0•r3 gallons
Reason for pumping. (_' GtCc.[,
TYPE OF -SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) _
(revised 8/15/95) 5,
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.w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 0� / �1� ,i,J1 DO V t L..0
Owner:' C
Date of Inspection:
SEPTIC TAN K:ye s
(locate on site plan)
Depth below grade:
Material of construction: _concrete metal _FRP _other(explain)
rl imoncinnc•
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffler".
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
inteerity. evidence of IPakaop atr 1
' ' .IiRCAJC 1 roar" r . • '. - ,
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of «um in bottom of outlet tee or battle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8/15/9;5) 6
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
fu c(���
0
TIGHT OR HOLDING TANK:_
(locate on site plan)•,
Depth below grade: s.
Material of construction: _concrete _metal _FRP —other(explain) r
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm .level: .
Comments: `
(condition of inlet tee, condition of alarm and float switches, etc.)
l
DISTRIBUTION BOX:-yf
(locate on site plan)
Depth of liquid level above outlet invert:/c &.2 .
Comments:
(note if level and distribut;cr is equa!, evidence of so!id� carryover, evidence of leakage into or out of box; etc.)
//d (Wity au -e✓
PUMP CHAMBER:_
(locate on site plan)
Pumps in'working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95)
C.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
(4
Property Address: Q (44 L
Aq of V .
Owner: M (�*q
Date of Inspection: A
SOIL ABSORPTION SYSTEM (SAS):_Ip
(locate on site plan, if possible; excavation not, required, but maybe approximated
roximated by non -intrusive methods)
If not determined to be present, explain: .
In-io fji e
Type:
leaching pits, number:_
leiching chambers, number:
leaching galleries, number:
2 leaching trenches, number,Tength: 3 Al
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic level of ponding, condition of vegetation,etc.)
Y/p 1& 104
1 17
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater.
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
_ ;& try.
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95)
R
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: //0Owner: !�
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100`
,i
bEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation:
DL, G p o w"
NV c.u.a uf3s-evo<
r
(revised 8/15/95) 9
Commonwealth of Massachusetts [R,ECE'VED
City/Town of
System Pumping Record JN - 8 2009
�. Y p 9
FOPfill N OF NORTH ANDOVERALTH 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.
,l
A. Facility Information
Important:
When filling out
forms on the
computer, use
only the tab key
to move your.
cursor - do not
use the return
key.
VILA
1. System Location: Leftfr ,left rea left si a of house fight front, right rear, right side of house.
Address �4-
Citylrown
2. System Owner:
Name
Address (if different from location)
Cityfrown .
B. Pumping Record
1. Date of Pumping
3. Type,of system: El
V1 L .X < -
State
Zip Code
Staff` Zip Code
Telephone Number
Date 2. Quantity Pumped: Gallons
Cesspool(s) eptic Tank LD Tight Tank
jj Other (describe):
4. Effluent Tee Filter present? Yes If yes, was it cleaned? p Yes [j No
5. Conditi n of Syste : 11 r
'o' bz'A'Cr&A'
" r <
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7.. Locatio ere contents were disposed:
L.S.D Lowell Waste Water
of
F 5821
Vehicle License Number
Date
— C-�` (nq
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts RECEIVED.
City/Town of
-
System Pumping Record JUN - 5 2006
Form 4
TOHEAOF RTH �
TER
LLTH DEPARTM
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 fining out
forms to the
computer,. use
1. System Location:
�""' \ CJ's J LJ
only the tab key
to move your
cursor do
Address
- not
use the: return
CityfTown Sta a Zip Code
key. .
2, System Owner:
Name
Address different from
(if location
CityfTown Stat -Zip Code: .
Telephone Number
B. Pumping Record
r--
1: Date. of
Pumping Date 2. Quantity Pumped -
Gallons
3. Type of system: ❑ Cesspool(s)a tic Tank
P ❑ Ti9 ht Tank
❑ Other (describe)..
4. Effluent Tee Filter present? ❑ Yes Q-Nc-� If yes, was it cleaned? E] Yes ` ❑ No
S: CondAtioA`n` of System:
6: Sy it m Pumped BY;'
¢-- t
'Name m
Vehicle. License Number
Company
Z. Lo n where contents re disposed:
L.
Sig lur of ti ter +;
Date
hftp://www.mass.,gpvldep/water/aPptovalg/t5fon,ns..htm#inspect '
t5f orm4.doc• 06/03
System Pumping Record Page 1 of 1
TOWN OF NORT�ANDOVER
SYSTEM PUMPI G RECO RECEIVED
�`
DATE: 11- 11 -6q NOV 19 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMiENT
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
6 f4 -c. ( � I�',
LA-�
ttvtda--q-e4: j"eck—
DATE
OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SE ,TIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: 61
L -S. ..
Commonwealth of Massachusetts
City/Town of
a a° System Pumping Record
Form 4
DEP has provided this form for use by local Boards of
information must be substantially the same as that pro,
local Board of Health to determine the form they use. l
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of house, Right front of house,
eft rear of hous ight rear of house. Left rear of building. Right rear of building.
Address
N -
City/Town State Zip Code
2. System. Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
State Zip Code
Telephone Number - n
Cod
1. Date of Pumping 5-1- l () 2. Quantity Pumped'
Date
3. Type of system: ❑ Cesspool(s) /Septic Tank
❑ Other (describe): Z
4. Effluent Tee Filter present? ❑ Yes [g No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
VIIIA' Le,
Company
7. Location where contents were disposed:
L .D ,j Lowell Waste Water
of
t5form4.doc• 06/03
F5821
Vehicle License Number
Date
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
W° System Pumping Record
Form .4
DEP has provided this form for use by local Boards of
information must be substantially the same as that pro,
local Board of Health to determine the form they use. l
the local Board of Health or other approving authority.
A. Facility Information
but the
check with your
be submitted to
1. System L tion: Left front of house, right front of house, left side of house, right side of house,d
ar of hou , right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner. S'
t
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
State �3 71
� Zip Code
Telephone Number CJ�
2 Quantity Pump ed'
Date Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes L_No
5. Condition OSy$tem:���
6. System Pumped By:
Neil J. Bateson
If yes, was it cleaned? ❑ Yes ❑ No
Name
Bateson Enterprises Inca
Company
7. Location where contents were disposed:
Of
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
_A.
IM City/Town of
System Pumping Record`
Form 4
i r►� ne �q..i :�l G� SCR
V1 1 �!eF • r W[ iry i
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may a used, u 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 / Right front of hous , Le / RighrAja of hou , Left / right side of house, Left /
Right side of building, Left / Right front of bu ding, .Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
State
Zip Code
State p
.�
i o e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped
3. Type of system: ❑ Cesspool(s) Septic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [I -No
5. Condition of
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location w contents were disposed:
_ Lowell Waste Water
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
�L<'�S (r
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1