HomeMy WebLinkAbout2000-2015 - Septic Pumping Slip - 261 REA STREET 2/24/2020 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for usezby 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 Locati : Le + Righ fr nt of ho s Left/Right rear of house, Left/right side of house, Left/
Right side of buit�dirtrtag. Left/Ri of building, Left/Right rear of building, Under deck
9 9 g�
Address 1 "cc V�
y
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
State
h115
`7 q9 Y �.
Telephone Number
B. Pumping Record
1. Date of Pumping Date �;eptic
�Quanumped: Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Lam'No If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of System:
V\-
6. System Pumped By.-
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LkHau
tents were disposed:
GL Lowell Waste Water
SigWUDate
t5form4.doc•06103 System Pumping Record•Page 1 of 1
L\ Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
M
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
City/Town State Tip Code
2. System Owner:
Name
Address(if different from location)
City/Town State
Telephone Number
i
B. Pumping Record
Af
1. Date of Pumping Date 2. Quantity Pumped: Gallons ..
3. Type of system: ❑ Cesspool(s) El--Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiop of}System: jI
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company .
7. Loca h e contents were disposed:
L
7G L S.Q Lowell Waste Water
4SigntrbauleV����� Date F
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
M
JIB _
DEP has provided this form for use by local Boards of Health_ Otherforms 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 Locatio e Rigta�ron
ont of house eft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ o building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner: t
Name
Address(if different from location)
City/Town State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ 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. Location where contents were disposed:
G_L S. Lowell Waste Water
C4
Sign't e Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of RECEIVED
o System Pumping Record
Form 4 DEC -8 toil
GSM
DEP has provided this form for use by local Boards of Health. Other f r=information must be substantially the same as that provided here. Bef r ith 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 Locatio L Rigprt f nt of hous�Left/Right rear of house, Left/right side of house, Left/
Right side of buil Ing, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown ( ` J State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
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 []-�o If yes, was it cleaned? ❑ Yes ❑ No
5. Condi on of System: /
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
Sign toe cfHauieV Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
\ Commonwealth of Massachusetts - -
C ity/Town of
System Pumping Record Nov - M19
Form 4
TOWN 00 NORTH ANDOVER
DEP has provided this form for use by local Boards of Healt QW&MUMP N7 but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ 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 side of house, Right side of house Le�front 'Right front of house,
Left rear of house, Right rear of house. Left rear of building. ding.
Address ` eell c D�
City/Town State Zip Code - --
2. System Owner:
Name
Address(if different from location)
City/Town Stag C ? ` Zi
c/eJj .' nl f �
Telephone Number
B. Pumping Record
1. Date of Pumping pare 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): --- ----- - -- --- - ---
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiop of,Sy stem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati where contents were disposed:
G.L.S. Loy4ell W ste Water
Signaturg6f Ifa#r Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JUN 15 2009
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other for
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: ft fro t ft rear, left s of house. ight front, right rear, right side of house.
forms on the
computer,use
only the tab key Address
to move your ��-- b(J
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner
Name
Address(if different from location)
City/Town State^ S�' Zip Code^Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: 8 Cesspool(s) eptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? 0 Yes 0� If yes, was it cleaned? Yes No
5. Condition off,Syste��-�cJL
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
.S.D Lowell Waste Water
G -- � � -Q �
igna ure of H Or Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
�L\ RECEIVED®Commonwealth of Massachusetts JUN o 9 2008
City/Town of
System Pumping Record TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 detemUne 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 fining out 1. SySi�em LC�� C �C �
forms on the
computer,use
only the tab key Address
to move your
cursor-do not Cityrrown State Zip Code
use the return
key. 2 System Owner:
Name
Address(if different from location)
City/Town State Zip
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ej--No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition
kei a � v\-
6. System Pumped By: Gcd�&� �—L-) r
Name (13,-( Vehicle License Number
Company
7. Locatio ere con nts r disposed:
Sign re Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF _
SYSTEM PUMPING RECORD
DATE. OCT 1 2 20 5
TOWN OF -R
HEALTH "f
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house
DATE OF PUMPING: C QUANTITY PUMPED : C GALLONS
CESSPOOL: NO 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(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
.t1,€ Y'.,,�K i 3 7.
i
I i Ale,
..,...... Wes.._... ... - .. ...._. - 2
e ' }I{} .f i'yf•;
Lz,:�.t.�k .. a Tj�l�F��:` b,��F
L)A i k s Y$7141k I P U M P I N Q RE('0 Kj,
ADDRES -----------
DA TI OF PVW�-Q
NA rUK6 O)l
Qtl3bA'VA
RECEIV D
xMAWY OVJIA3B
K 00'rs L&AvC HPI&q AUG 12 2005
"C"SIVE SOLIDS .- trLWDer) _D KUNbA�,'O,
SOL rD CA KA YC) LAIN TOWN F NORTH ANDOVER
HEALTH DEPART ME NT
,o �. ..
4 >_.
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� �k. �\ • �
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_. _ } _.
.. � :.h.
TOWN OF NORTH ANDOVER
SYSTEM PUMPING ORD
DATE �'o?�Oy RE
SYSTEM OWNER& ADDRESS SYS M LOCATION
S
DATE OF PUMPING: "a��Q QUANTITY PUMPED: d�
CESSPOOL: NO /YES Septic Tank: NO YES
NATURE OF SERVICE: ROUTINE v` EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
System Pumped by
COMMENTS:
CONTENTS TRANSFERRED TO
r.
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WN OF NORTHAPO0VFR
SYSTEM PUM'PI.NC PS-CORD
r
>> I'CM OWNER & ADDRESS w. SYSTEM LOCATION
(ez4mp,Ie: Ick iron( of house)
UATC OF PVMPINC �tre QUANTITY OUMCDLl c» 1
NO YES SEPTIC TANK; N0 YES ✓
.w
X -NUKE OFSERYICE: ROUTINE EMERCENCY
II.SrRY� T10NS;
CUUD CONDITION, FULL TO COYCH
HRAYY CREASC BAFFLES IN P'LACP
ROOTS LEACHFICLD RUNBACK.,•
CXCESSI'YE SOLIDS FLOODED'
SOLIDS CARRYOYER .,PJ HEft (EXPLA.)N)
>>'>'I'LM PUM ('CD 0Y,
,
C•U.11 kl rNTS, _ . . •
0� I'1:'^4'rs' !'1 AN FC, BRED TO
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
S1 STEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
D:%TE OF PUMPING: Jr' �l d /"" QUANTITY PUMPED 1000 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE X EMERGENCY
0BSERVATIONS: /
GOOD CONDITION FULL TU COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM P U M P ED BY:
/
C'u�ItiIEN�rS: ���� t � l�L��r,
CONTENTS TRANSFERRED TO:
u
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: �—
' SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
36
jV0,qP0,4V,
DATE OF PUMPING: 57d 2J QUANTITY PUMPED=GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE. EMERGENCY
OBSERVATIONS: r
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS C A RRYOyER OTHER (EXPLAIN) N
4 ,
SYSTEM PUMPED BY:
}
COMMENTS:
`. CONTENTS TRANSFERRED TO:
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