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- 1
Commonwealth of Massachusetts FREE
= City/Town of System Pumping RecordForm 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 hous. 22ding,
rig Id of hous eftRight side of building, Left / Right front of building, Left / Right rear of Un er eck
Address c z-�) DC � S1+
City/Town
State
2. System Owner.
Name
Zip Code
Address (if different from location)
City/Town Stan�/�' � ! Zin Code
1
Telephone Number
_ t
i
B Pumping Reco d
1. Date of Pumping Date 2. Quantity Pumped
eptic Tank
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 9No
5. Conditionr7T
:
��
6. System Pumped By:
7.
I L �<
Gallons -Y
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
Neil. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
contents were disposed:
Lowell Waste Water
to _rY
or
Date
t5form4.doc- 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
����
City/Town of
System Pumping Record 'r�
Form 4 IIMN i 9*
DEP has provided this form for use -by local Boards of He �' �R--"'' ed, 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 house4�GP/ right a of I�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
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State� Zi Code
Telephone Number
-4;- �3
Date 2. Quantity Pumped
Cesspool(s) eptic Tank
`Or -2>
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi n of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
a S. Lowell Waste We
—#
Date
t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1
Commonwealth of Massachusetts
® uvSu—, Massachusetts
System Pumping Record
System Owner
Date
of Pumping
Cesspool: No [V
System
Location
93,0 Tr,l�- 4-
Jt I2 • )-b-00 Quantity Pumped: I) 0 Do gallons
Yes L..) Septic 'Tank: No L:.J Yes vi
System Pumped by: Fdrejea Srfa7 lied License #
Contents transferrred to : Greater Lawrence Sanitary District
Date:
Inspector
Common yea It of Massachuselts
of
System Purnping Record
System Owner
D (tA e,(-
Date of Pumping: q
Cesspool: No N Yes �..)
System Location
_TCev�
Quantity Pumped: C� gallons
Septic Tank: No Yes
System Pumped by: verredere Kee ii0ed License #
Contents transferrred to : Greater Lawrence Sanitary District
Date:
Inspector:
F TOWN OF NORTH ANiQCM t k, r
130ARD OF HEALTH
APR 2 61999 ;
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Ocher
�<t a tA Q,�-
Late of Pumping: � � �— l
Cesspool: No Yes L:_l
System Location
Quantity Pumped:
Septic Tank: No U
System Pumped by: aadoa Erf&,�6wej License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: -_ Inspector:
Yes
gallons
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 5 -1 "0 �L_
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: '-I-b� QUANTITY PUMPED (G�y GALLONS
CESSPOOL: NOYES SEPTIC TANK: NO YES
—(SLl
NATURE OF SERVICE: ROUTINE J 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)
�Owel
r�el(
L Commonwealth of Massachusetts
City/Town of 1
System Pumping Record AUG 1 1 200
Form 4
w TOIv OF NORTH AND
NEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. fie SystemPumping Rei
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
.Important:
When filling out 1. Sy em Location: , S
forms the
computer.. use
only the tab key Address
to move your
cursor - do not
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address (if different from location)
City1rown State
e
Telep one Number
h.ttp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc• 06103
B. Pumping Record
1. Date. of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑e5- ptic Tank- ❑Tight Tank
❑ Other (describe):
4: Effluent Tee Filter present? El Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Svstem• ., t
6. System Pul
A
Name
Company
7. Locatio% re
Ute.
By:
k
Date
system Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your.
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Oth
information must be substantially the same as that provided here.
local Board of Health to determine the form they use. The System
the local Board of Health or other approving authority.
A. Facility Information
1. System
RECEIVED
MAY 2 6 2009
,�k with your
submitted to
rear, left side of house. Right front, right rear, right side of house.
Address `--� j I
City/Town
2. System Owner;
ri
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: 8
Ij Other (describe):
State
Zip Code
State Zip Code
6
Telephone Number
—d ( 0 2. Quantity Pumped: J �J�
Date Gallons
Cesspool(s) Septic Tank Tight Tank
4. Effluent Tee Filter present? El Yes & No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water
If yes, was it cleaned? p Yes [j No
F 5821
Vehicle License Number
of Kujbr Date
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of
j
System Pumping Record MAY 2 1 2008
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other y used, ut 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 LOCatiOrl:
forms on the
computer, use
only the tab key Address
to move your� fUt,_ ,eA:Z��
cursor - do notC
use the return State Zip Code
key. 2. System Owner:
Q1 �..�
Name
Address (if different from location)
CitylTovvn State
, r. I
Tee one Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:. Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
[I Other (describe):
4. Effluent Tee Filter present? ❑ Yes E] -No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System pumped �y`
Name ,w
\v Vehicle License Number
Company
7. Location
t5fonn4.doc- 06103
were
Date
System Pumping Record . Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record R" off
Form 4
Ulu JUN / 2010
I
DEP has provided this form for use by local Boards of Health. Other f ma be used, but the
information must be substantially the same as that provided here. Bef rN Pith your
local Board of Health tQ determine the form they use. The System Pu itted to
the local Board of Health or ottxer approving authority.
A. Facility Information
1. System Location: Left side of hous iht of hn� �� ft front of house, Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address (if different from location)
Citylrown
B. Pumping Record
1. Date of Pumping
3. Type of system:
❑ Other (describe)
Telephone Number
L11_to
Date 2- Quantity Pumped: Gallons
❑ Cesspool(s) EJ-15e�ptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ 8
5. Conditio of System
w k
6. System Pumped By:
Neil Bateson
7.
Name
Bateson Enterprises Inc
Company
L.S.
Signature
contents were disposed:
/J Lowest YVaA Water
If yes, was it cleaned? ❑ Yes ❑ No
F5821 '
Vehicle License Number
Date
t5form4.doc- 06103 System Pumping Record . Page 1 of 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 ay
information must be substantially the same as that provided here. Before u ing
local Board of Health to determine the form they use. The System Pumpin Re
the local Board of Health or other approving authority.
A. Facility Information _
1. System Location: Left front of house, right front of hous left side of
rear of house, right rear of house, left side of building, right rear of bu
City/Town State
2. System Owner:�-
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe)
:ord must be submitti
juN -4 2011
VN OF NORTH ANDOVER
LTH DEPARTMENT
h-0-TF§ "I
under deck.
Zip Code
State60 i OpCode
Telephone Number
2. Quantity Pumped:
Date Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Conditirt7m�
0,4, � �A 4e':It�
1
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Lo here contents were disposed:
Z.G.L.S.D. „LcAll WasteWa er
Of
F5821
Vehicle License Number
Date
to
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of JUN U b 2012
System Pumping Record
TOWN OF NORTH ANDOVER
Form 4 HEALTH 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.
A. Facility Information
1. System Location: Left / Right front of house(l@fl Right q Car ho ,Left /right side of house, Left /
Right side of building, Left / Right front of building, Left / Rightrear of building, Under deck
Address
Cityrrown
2. System Owner:
Name `
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State
Zip Code
state /Zip Code
%$';�-6-71
Telephone Number
1 5,- 12
Date 2. antity Pumped.
Cesspool(s) Septic Tank
4. Effluent Tee Filter present? ❑ Yes & No
5. Condition of System:
IM
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location re contents were disposed:
S. Lowell Waste Water
—0
IC)y
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
'K- Ls- LA
Date
t5form4.doc• 06/03 System Pumping Record . Page 1 of 1