HomeMy WebLinkAboutMiscellaneous - 97 COMMERCE WAY 4/30/2018r
Commonwealth. of Massachusetts \
City/Town of 1 RECEIVED
System Pumping Record
Form 4 APR 0 3 2006
DEP has provided this form for use by local Boards of Health. Th.gcTGSystem,"Pumpin'gc!
be submitted to the.local Board of Health or other approving autt�orl¢tyEALTH DEPARTMO
A. Facility Information
Important:
When filling out 1. Syst �ocation:
forms the 4
computer, use
only the tab key Address
to move your
cursor - do not
use the return City/Town St to Zip Code
key.
2. System Owner: ea,
Name
Address (if different from location)
Cityffown
StaWl
ly Code'
Telephone Number
B. Pumping Record
1. Date. of Pumping Date 2. Quantity` Pumped:
Gallons
I Type of system: ❑ C.esspool(s) eptic Tank- ❑ Tight.Tank
❑ Other (describe):
4. Effluent Tee Filter pfesent? ❑ Yes Mho If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f System:
must
SigAu of auler
http://www.mass.gov/dep/water/ppptovalt/t5forms.htm#inspect
t5form4.doc• 06103
TOWN OF NJ '
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
LVED
APR 1-3 2005
TC,,. .. , N AN
(example: left front of house)
a
_J
DATE OF PUMPING: QUANTITY PUMPED : ` `� GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste