HomeMy WebLinkAboutMiscellaneous - 187 STONECLEAVE ROAD 8/20/2015 ' I
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Commonwealth of Massachusetts
= City/Town of
System Pumping Record
Form 4
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DEP has provided this form for us&by local Boards of Health. Other f �rrnSvpj, y b�qsedr but the
information must be substantially the same as that provided here. Befre t�sapg frrt d(iaak Ith your
f r« r� �,
local Board of Health to determine the form they use.The System PumpingRaordt;Ps ��t emitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/Right front of house, Left/ rear of house,LLeft, right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear ofi building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' State Zd�
,.
Telephone Number `w
B. Pumping Record R
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ® Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ®' � If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of ys em:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatia ere contents were disposed:
aLS-D Lowell Waste Water
SignAtufe cfHauleV Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts `
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City/Town of ti 1
a System Pumping Record
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Farm 4
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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 i h rea�rear Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/ Ig uilding, Und er deck
Address �' 1 �.���`�_,�..��,�..,�...✓� �`��'"w� `^"�
Cityfrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town �
Stat - Zip Cqde _
t�
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 om 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. Loca ' ere contents were disposed:
G.L S. Lowell Waste Water
L�M JA. I
Sign toe cf Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
Recal
City/Town of
RECL
System Pumping Record NIR 11 ?011
Form 4a
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N
TOWI O F NORTH ANDOV1 ER
GA 5
R
DEP has provided this form for use by local Boards of Health. Other forms Mg DMADY-Er.-N—T
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 Locatioq;-Vetfront-of.house, right front of house, left side of house, right side of house, Left
rear of houE a
�6,'66ht rear of house, side of building, right rear of building, under deck.
Cityfrown State Zip Code
2. System Owner:
Name
Address(if different from location)
-(;4d
j p
e
City/Town St 9
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) H—S—e—pf—ic"Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition pf System:
lub
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locat' rr here contents were disposed:
L.S. . AowelMaste\(Ater,,--,
SignatuKe okfiaugr Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
City/Town of
'Y03
System Pumping Record
Form 4 Irt)W"C'WI N09114 ANDOWErt
4 4W 11 O
I "t
rij FPARTMENT
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 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, Left front of house, Right front of house,
Left rear of hous ft rear of building. Right rear of building.
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown ST7 q C_t iV e
Telephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) EI�Septic Tank ❑ Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 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. Locatio er contents were disposed:
G.L.S.D,_,
Lgwe"aste Water
u
Signat�e/11-14-ler Date
r
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of RECEIVED ,
mm
City/Town of
}` System Pumping cor JUN 3 0 2009
Form 4
..IOWN OF LN(R-T H An~wdCOVER
DEP has provided this form for use by local Boards of Health.-Ot et . .. ' h16 k 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 Impo
Wh nrtflling out 1. System Location: Left front, left rear, left side of house. Right fratY;right r ar, ght si of o e
forms on the
computer,use
.. - ,
only the tab key Address t to move your
cursor-do not
use the return Cityfrown State Zip Code
key. — 2 System Owner:
Name
Address(if different from location)
Cityrrown Stag Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) Ej-'Septic Tank [j Tight Tank
Other(describe):
4. Effluent Tee Filter present? Ll Yes No If yes, was it cleaned? Yes No
5. Condition of System:
ro,A.e-Al ( ., "
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio_R3mbere contents were disposed:
L.S.D Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
i
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Commonwealth of Massachusetts J U N I
City/Town of 1
System Pumping Record i .�..
, y
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
i
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling out 1. System t_OCatIOn:
forms on the v l �
computer,use
only the tab key Address
to move your City/Town
cursor-do not
use the return Y tale Zip Code
key. 2. System Owner:
Name
1
Address(if different from location) �
City/Town St e Zip Code
' -� -
Telephone Number
i
.B. Pumping Record
1. Date-of Pumping Date 2. Quantity Pumped: Gallons
1 Type of system: ❑ Cesspool(s) [r" p is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑T'C If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System P mied By"
Name > Vehicle License Number T
Company
7. Location w &61p ntents wer posed:
ltr--
�-lee
Signal e bf H uler Date
hftp://www.mass.gov/dep/water/.approvals/t5forms.htm#inspect
t5form4.doc•06103 System'.
ystem Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
Massachusetts
Pumping System
System Owner System Location
1
CI f� � '<S4,"e_cJ-0,x,
Date of Pumping: f Quantity Pumped: /";� g allons
Cesspool: No [ Yes [] Septic Tank: No [] Yes [
System Pumped by: License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
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u pjngjLeoord
System Vocalioll
Polo cif 1►omping: C � '°
Quailti{y Pumped:
ss auc�l: Nct ( Yes _� Seplic Took: No I :l Yes [
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���1+�l1{ 1'ut�►l�ed ��. '��"�"�tA�fi ��'.��'�� License #
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