HomeMy WebLinkAboutMiscellaneous - 251 GRANVILLE LANE 4/30/2018 (2)U 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 hous, Le Right ar o hou e , Left / right side of house, Left /
Right side of building, Left / Right front of bul Ing, Left / Right rear of building, Under deck
Address 4t ( CCDCOAjw �,ke Lsc�"� A,)Or4�, AL^6p
Cityrrown State Zip Code
2. System Owner.
Name
Address (d different from location)
City/Town StatZip Code
Telephone Number
B. Pumping Record
V-) ----c3 l
1. Date of Pumping 2. Quantity Pumped: n
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No:
5. Condition pf System: ,� ` , V.\I- 415(,�„
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc -
Company
7. Location re contents were disposed:
Cx s Lowell Waste W,
0.l
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
N
AM
H
4-
O
N
Z
I�
I
C
_O
Q
N
E
0
0
w
0
m
°c.
L
L
O � �
a0+
2 O
E16 'ET A
N
O E C
OO4.5 U ,0
�CQ
O
t—
G
O
Q
C
N
�
U
O
C ,
a � �
QV
E
"1--+
L
ro
C.
Q�
0
C
L
m
I
c
O
V)
V)
E
O
u
c
0
0
i
O
U
I
O
m
C
C
CL
i
ra
O
Company'Address
3;,3.. w A � K E:2 ,� n � . � ti � d ✓ r 2 fT,a�, ,
at
and
13
fails
in
in
and
A2 TT17f ITT2FAC!E
SEWAGE
DISPOSAL
M SYSTEM
INSPECTIQN
FORM
Company'Address
3;,3.. w A � K E:2 ,� n � . � ti � d ✓ r 2 fT,a�, ,
at
and
13
fails
in
in
and
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: �e-1
SYS
'C�l
Z51Grp �e
(example: left front of house)
DATE OF PUMPING: co -111'61 QUANTITY PUMPED_(8e--) GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
COMMENTS:
ti -
CONTENTS TRANSFERRED TO: [ L - .
a
Commonwealth of Massachusetts
City/Town of -
w° System Pumping Record'
Form 4
GSM SyQ�
DEP has provided this form for use by local Boards of Health
%% t% but the
information must be substantially the same as that provided r%j . , . itgtttt�is.lficr check with your
local Board of Health to determine the form they use. The Sys moing ecor must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. Syste ation: Left front of house, right front of house, left side of house, right side of hou , Left
ear of h -sq fight rear of house, left side of building, right rear of building, under deck.
Cityrrown State Zip Code
2. System Owner:
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date
Cesspool(s)
Zip Code
Telephone Number
�eptic
Quan Pumped
Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System�J�
(k)f)S �OuAf
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Lo"ere contents were disposed:
L.
F5821
Vehicle License Number
Date
9 —,Z)6 ` le,
t5form4.doc• 06103 System Pumping Record • Page 1 of 1