HomeMy WebLinkAboutMiscellaneous - 544 JOHNSON STREET 4/30/2018 (2) � �
II
Commonwealth of Massachusetts
City/Town ofCLi •
° System Pumping Record
Form 4
M 5 e
DEP has provided this form for use by local Boards of Health. OthLUSH TIV Tt[�6dib)3kwithyour
information must be substantially the same as that provided here. �ic�
local Board of Health to determineh
t e 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.<i"g rear of , 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)
City/Town Stat i Codes
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? ❑ Yes Imo'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LonLS.
h contents were disposed:
Lowell Waste Water
SignAtula, Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
Commonwealth of Massachusetts
fV
City/Town of _
System Pumping Record OCT 9 2008
Y p 9
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
Important: /
When filling out 1. System Location: Left front, eft req , left sid of house. ight front, right rear, right side of house.
forms on the
computer,use
only the tab key Address lJ l \ V C/l`1J1 <✓ ' �` �-�
to move your �
cursor-do not
use the return City/Town State Zip Code
key. 2 System Owner: 1^
Name
iC3 Address(if different from location)
Cityrrown Sta z7iQ Code
Te ephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: 0 Cesspool(s) eptic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes 8'1qo If yes,was it cleaned? 0 Yes L] No
5. Condi ion of System:
Cl C�s
C�
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
C� (example: left front of house)
bO&
Sqq Sb J
DATE OF PUMPING: - N` 6 QUANTITY PUMPED : (. p7C GAL ONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAES)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
coNTENTs TRANSFERRED To: G.L.S.D Lowell Waste