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HomeMy WebLinkAboutMiscellaneous - 22 RALEIGH TAVERN LANE 8/24/2015 Commonwealth of Massachusetts City/Town of System Pumping-Record 2 3.201.5 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 1. System Location ""eft Right ont of hoes Left/Right rear of house, Left/right side of house, Left/ Right side of bull mg, Left/ Righ ron of building, Left/Right rear of building, Under deck Address Citylrown State Zip Code 2. System Owner: Name* Address(if different from location) Cityrrown ' Sta ZiRCode Telephone Number B. Pumping Record �. 1. Date of Pumping Date 2. Quantity Pumped: Gallons r 3. Type of system: ❑ Cesspool(s) 0-1 *tic Tank [I Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep ",.µ.. If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of stem: 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 SignAtula,9t Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 1 Commonwealth of Massachusetts i u City/Town of a System Pumping Record Form 4 gV� 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/� Ri frori of house Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Rig ft��uildirig, Left/Right rear of building, Under deck 9 1 _ ...... V 1�...1 C Address rf � ( .. ..fl� i-� Citylrown "j State Zip Code 2. System Owner: Name' Address(if different from location) (J Citylrown Sta � t°C Code Telephone Number i' B. Pumping Record 1. Date of Pumping Date 2. Qua tity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) CrSepticTank ❑ Tight Tank ❑ Other(describe): 4, Effluent Tee Filter present? ❑ Yes ® o If yes, was it cleaned? ❑ Yes ❑ No; 5. Conditioln of System-.C�A Q 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Numbed Bateson Enterprises Inc' Company 7. Locationre contents were disposed: G L S. Lowell Waste Water RD Sign t e Haute Date t5form4.doe-06/03 System Pumping Record•Page 1 of 1 I f 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 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�Cw❑Rig front of house;left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Rig rontof building, Left/Right rear of building, Under deck Address r CityfTown 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) ' E Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes � No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: sl 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water Sign t e HaulerU Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts oftO RE,,CEIVED City/Town of System Pumping Record Form 4 TOWN OF NORTH ANDOVER I,EALTH 14"P R"rMEN 11, DEP has provided this form for use by local Boards of Health. Other for vjjjjy+6-6Q;-but`t1ye- 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 ]ER rear ofhouee Left/r�hta�eofhouoe Left/ /' oyu*m// ^"^�°" ' ^�' building,Right/R�htneorofbuikUnQ. Undardack Left ip Code cityrrown state R�ht�deofbuUd|nQ, Le�/ m�ru/nzn�u" �� . �=` �~ 2. System Owner: Name State Zip Code Te-lephone Number B. Pumping Record 1. Date ofPumping o�a 2. {]uanUb/punn�e�� Gallons 3. Type ofsystem: D Cesspool(s) 'a-S�pbcTank F-1 T|OhtTonk [l Other(describe): 4. Effluent Tee Filter present? Ej Yes c�� |f yes, was it cleaned? F� Yes U No 5 (��nd of � \ \~ � �--� - - � /� �U^\� p�/ /-�� U~�\L~�~�� \�~- -- `_~ O. System Pumped By: Neil Bateeon F5831 Nume Vehicle License__ Bateson Enterprises Inc Company 7. Location_ h t�ntovvenedisposed:Lowell Waste Water "'7 t5fonn4duc-88/03 System Pumping Record~Page 1uf1 Commonwealth of Massachusetts City/Town of °" � w System Pumping Record Form 4 M ; i DEP has provided this form for use by local Boards of Health. Othe ftt information must be substantially the same as that provided here. B *iaetng. rrrr°� 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 . Left front of hous'i right front of house, left side of house, right side of house, Left rear of house, righ r se, side of building, right rear of building, under deck. Cityrrown State Zip Code 2. System Owner: j Name Address(if different from location) City/Town State in Cod�e�p Telephone Number B. Pumping Record 1. Date of Pumping oat 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Ic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ©° Nom If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location where contents were disposed: G.L.S.D. owell a ater Signa r f uler Date I t5form4.doc•06103 System Pumping Record-Page 1 of 1 I 1 Commonwealth of Massachusetts RECEIVED City/Town of KC 1, 5 2,009 a° System Pumping Record �AkND V ER Form 4 TO jjEAL�H[)E�ARTMEN' 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 t4 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 houst Left front of hous 7 Right front of house, Left rear of house, Right rear of house. Left rear of building.`Ri o building. Address City/Town lJ StateC Zip Code 2. System Owner: Name Address(if different from location) City/Town Stffte-� 7 Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gauons 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 Systmc_'� \ — 6. System Pumped By: Neil Bateson — F5821 — --_ Name Vehicle License Number Bateson Enterprises Inc Company 7. Location _ e contents were disposed: U�.L.S.D Lowell Waste Water — Signature of Hauler Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 i v Commonwealth of Massachusetts � City/Town of System Pumping Record o Y p Form 4 SV 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. SySt m Location: y forms on the - �W S< computer,use only the tab key Address �13 to mane your cursor-do not City/Town State 7rp Cade use the return key. 2. System Owner: Name rim Address(if different from location) —7jp'Code City/Town Stat ! �l J cCl 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. Candi 'on of System: s. syste Pumped By: Name � . Vehicle License Number Company 7. Locati yvhere co ent ,re disposed: Signatu ler Date System Pumping Record Page 1 of 1 t5form4,doc•06/03 I ,,. Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Th °°System Pumping. eoor, must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use only the tab key Address to move your L -` '' �✓�. � e7 } ' cursor-do not use the-return Cityfrown State Zip Code key. 2. System OWner. F VV Name Andress(if different from location) CityfTown Stat Zip Code' Telephone Number i B. Pumping Record .. 1. .Date.of Pumping 2. Quantity Pumped: Date Gallons 3. Type of s stern: ❑ Cess ool s e tic Tank ❑ Tight:Tank ❑ Other(describe): 4. Effluent Tee Filter p resent? El Yes ®°"'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: �6. System Ppmp d 3.T.- l - , f . 'Name" .= Vehicle�_icense Number Company 7. location ere ontent ere osed 'A R Signa le of ler Date http://www.mass.gpvldep/wa(er/approvals/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 TOWN F SYSTEM PUMPING RECORD r DATE: — Q( _ SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) tA -�'ok '3 - k DATE OF PUMPING: (n Q dL— QUANTITY PUMPED : t cj h(­� GALLONS CESSPOOL: NO J / YES SEPTIC TANK: NO YES / NATURE OF SERVICE: ROUTINE V EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIIFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAES) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: L° Ir 1 Commonwealth of Massachusetts l �F -Massachusetts System put" im Record System Uivner system Location a - . . Dole of Pumping: ��"' � �- � Quantity Pumped: gallons C „ Cesspool: No Yes septic Wank: No IJ Yes System Pumped by: varedda gfl ijej License # Contents transterrred to : Greater Lawrence 8a�it�ty t[Astrict Date: Inspector: �,�►►►►u►t►tt�reaill► or nlnssctcl►usclls M aSSEIChUrletis a "Sjii"c►►i Lnc'eiion q'A�T . 'w►► ►{►► `'t ���� � ; • �' rluanlit;� I'uittl,�di { Unlr or 1 I !► �' fir►�tlr 'I'n��► },i.+ Yes Cesspool: (a_ eS 0 Lice►ise N; Systeill Pumped by: Conlews Irn►tsivieJ lo: Dale _� lilspeclor i i I I t Co►N►nxonr -colth of Alassachusetts � MassachUSetts 'O ' G nktlW fi 1001001 u"0;'y _S—y°slen� oca loll nor I Date of Pu►npin ��� ' ( � Qunntlty Pumped! Cesspool: No ,�l es U rrnlie "i'nnl" NI, U Yes In System Pumped by: �� License Contents transferred tc t Date —^_ Inspector