HomeMy WebLinkAboutMiscellaneous - 165 FOREST STREET 8/25/2015 : 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: Left/ 1 ht front of house eft/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
Cityrrown State Zip Code
2. System Owner.
V�e� .l
Name' '
Address(if different from location)
Citylrown State / Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping bate 2. Quantity Pumped: Gallons t
3. Type-of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of System:
��
6: System Pumped By:
Neil.Bates ri ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents-were disposed:
S Lowell Waste Water
Signitufe ct Haule Date
t5fonM.,dov 06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts R WC r.--�J-e
City/Town of
JUL V ?012
System Pumping Record
[TOVWVN OF NOR H ANOOV�ER
DEP has provided this _- _ use-` local Boards - Health. Other forms_m_` __ _---. _---_
information must be as that 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 b»
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left 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 Zip Code
2. Gvot�nU Qvxn�r
'
moma
Address(if different from location)
City/Town St t
Telephone Number
�
. �
B. ���00�V��� ��
_ Pumping Record- -
b^~`� �
1. Date ofPunm 'ng 2. Quantity Pumped: �Gallons
Date 3. Type of : El Tank Fl Tight Tank
�l Other
4. Effluent Tea Filter Yoe If yes,was it cleaned? Fl Yes Fl No
_ Condit*_
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson �
Enterprises
Company �
7. Location where contents were disposed:
<GLS� Lowell Waste Water
t5fom*4.duc06m3 System Pumping Record^Page 1mx1
|
Commonwealth �� N�
�^n Massachusetts rRECEIVED
J,J7-
City/Town of
\,K
System Pumping Record �
Form 4 'TOWN OF NORTH ANDOVER
HEALTH DEPARTMEN'r
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must ba substantially the 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 nr other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of'hous— RJ
-qht front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of�uil=n
Address <
Cityrrown State Zip Code
2. System Owner: (
Name
Address(if different from location)
Cityrrown sqa Zip Cade
Telephone Number
��
�'
��. ��u00,� n� ecor /� ~_ -7_ //7
KJ / < `~
1. Date ofPurnping ~~ 2 Quantity
n�a ' ��~ � Gunvnn
3. Type nfsystem: El Cesspool(s) 2~SeotiuTanh Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? 0 Yes [3 No |f yes, was itcleaned? [l Yes El No
5. Condi r\
V \ � k\
\ ,f��\/ yv"~� C
8. System Pumped By:
Nei| Bataoon F5821
Name Vehicle License Number
0abeson Enterprises Inc �
Company
7. Looat �
SignaturVVot(laul r Date
mmnn4doc08N3 System Pumping Record^Page 1of1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 ...
DEP has provided this form for use by local Boards of Health. r"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. System Location:
forms on the ❑ —
computer,use r
only the tab key Address Y -->
to move your ❑ ❑ _ <❑ `' " ~ �tj 'r
cursor-do not Cityfrown State Zip Code
use the return
key. 2. System Owner:
C
Name
Address(if different from location)
Citylrown State ptt
Telephone Number
B. Pumping cor
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. Condition of Sy tem:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location e contents ere ' posed:
Signatu a offlaoer Date
t5form4.doc^06/03 System Pumping Record.Page 1 of 1
i
Commonwealth of Massachusetts
City/Town of
System Pumping Record
;l P J1 ° �
Form 4
ee e i
DEP has provided this form for use by local Boards-of Health. ho-system Pump ng Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important: ... r
When filling out 1. System Location: ,w•-.
forms on the ..: ..
computer,use
only the tab key Address - r
to move your ^ '.Iw � T ' ✓
cursor-do not i
use the-return Cityrrown State Zip Code
.key.
2., System Owner: ;
Name
Address(if different from location)
Cityrrown State p^ode
�° Zi �,
.. ) _...
Telep one N'Um er
.B. Pumping Record
1. Date,of Pumping da te 2. Quantity Pumped:
Gallons
3. Type of system: Q Cesspool(s) ❑_Septic Tank ❑ Tight Tank
❑ Other(describe):
4: Effluent Tee Filter present? E] Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S ystefn:
6. System P mped By
Name Vehicle License Number
Company --
7. Location where contents were disposed:
Si tture f uler Date
h.ftp://www.mass.gov/aep/Water/approval8/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
l
TON" OF w vi
SYSTEM P PING RECORD
DATE: iL s. 1l
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: loft front of house)
�aa i I
,
HATE OF PUMPING:
i
QUANTITY P ED : iW GALLONS
CESSPOOL: NO o, YES SEPTIC T •
NO s tr
1��1 OF SERVICE: IZO EMERGENCX
OBSERVATIONS-
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEAC LD RUN-BACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R O (EXPLAIN)
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
N'TS:
CONTENTS TRANSFERRED TO: .L. a L ell Est®
A