HomeMy WebLinkAboutSeptic Pumping Slip - 43 WINTERGREEN DRIVE 9/1/2015 i
Commonwealth of Massachusetts
x City/Town of
W?
a System Pumping Record �
Form Q�t�4�¢I�M� ������� s����� r �ii� 1
DEP has provided this form'for use by local Boards of Health. Other forms may be used, but the J
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 hous e /right4 ide house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 'J-�)1, k,� —
City/Town State Zip Code 1
J
2. System Owner: J
Name
Address(if different from location)
City/Town State C-- ��..Y ip 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 [�--No If yes,was it cleaned? ❑ Yes ❑ No j
5. Conditiop of,System: V\,
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 toe Hault;fu Date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
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System Pumping Record (
�
Form 4
DEP has provided this form for use by local Boards nfHealth. Other forms may be uaed, but the
information must be substantially the same aa 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 besubmitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left front, left rear, left side ofhouse. Right front, rightnaa
forms onthe --
computer,use
only the tab boy Address
tu move your L—( 3
cumvr-uo not
une�hon�um City/Town ^8(aVa Zip Code
key.
2. System Owner:
-----
Name
IP-W Address(if different from location)
City/Town State
Telephone Number |
/
B. Pumping Record
1 Date 2 Quantity� Date � � Gallons
3. Type ofsystem: Fl Cesspool(s) 9~�e ot�T�nk El Tight Tank
[l
Other(describe):
4. Effluent Tee Filter El Yes 0~146 |f yes,was itcleaned? Yee No
5. Condition
V\-
8. System Pumped By:
Nai| Bobaeon F5821 �
�
Name Vehicle License Number
�
Bateson Enterprises Inc
Company �
7. Location where contents were disposed: �
Lowell Waste Water
�iagnafu-re of'Hdj Date
Or
(5fnon4doo^0603 System Pumping Record^Page 1 «[1
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Commo weald of Massachusetts
(4-,vL1('-,eAf'ias sachuselts
l
stem ng Record
System Owner System Location
� .
10 "
tY71
W �
Date of Pumping: Quairtity Pumped: �� —g-"a I ons
� ,�. . U ���, �.....
Cesspool: No :� Yes U Septic Tank: No Yes
System Pumped by: t7ctre4oft ,rt&I 'tMed License#
Contents transrerrred to : Greater Lawrence Sanitary District
Uate: _ inspector:
f!
ECEIVED
OCT 0 6 2004
TOWN OF N RTH ANDOVER
SYSTEM P mPINQ RECORD TOWN 0F t,,10 RvH
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L)A k HEAL D 1rwrirKw
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tiYS1'`F.M OWNER &t ADDRESS SYSTEM 1 L(JCA"T"fGN T'
0 0,4?�Vll:molv, ki
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DATE,OF PLIMPINO-
_.,._.._ °�.. QUANTITY PUMPED:..._.
Ck;SSP(X)L,.: NU Yf S Septic lank: NU YE:S 7
NA rUKE; OF SERVICE;: RUU'CINk '._. __...HMI RC3ENC'Y
Ob iERVA TIONS;
GOOD CONDITION FUI,L 'T'U COVER
HEAVY GREASE BAFFLES IN PLACL
ROOTS _ LEACHFIELD RUNBACK
EXCESSIVE, SOLIDS _ FLOODED
SOLID CARRYOVER'.......-OTHER EXPLAIN
SyatOm Punpcd b7 0&. _LsoI
c:OMMNN i'h
CON I EN I'S MANSI"'I:;RRED 1-0
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