HomeMy WebLinkAboutSeptic Pumping Slip - 82 PADDOCK LANE 10/13/2015 f
Commonwealth of Massachusetts
= City/Town of
System Pumping rd
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/Right front of hous% Righ ear of j�jis , Left/right side of house, Left Right side of building, Left/Right front of bul , Left/Right rear of building, Under deck
Address \
r--
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
CitylTown ' State < Zip ode
f �
Tel phone Number
B. Pumlping Record
1. Date of Pumping Date 2. Qu ntlly 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 stern:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Nu"nber
Bateson Enterprises Inc-
3,
b giM1 V
Com an i
If I
7. Location where contents were disposed:
"L, . Lowell Waste Water
' n t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
O A-
City/Town o f
L
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/Right front of house,<fe /Righ -' fhouss'-"�, Left/right side of house, Left
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address A
Cityrrown State Zip Code
2. System Owner:
LA�
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date f 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [J--No-' If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio of System*
'
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatg"on-wherejq'ontents were disposed:
GLS. Lowell Waste Water
Sign toe qt Hauler U Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
mow``"'"•,:�,..
Coi-nmonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 � �:iwr
I
DEP has provided this form for use by local Boards of Health. Other fo the
local Board of Health to determine the form they use. The System Pumping e ord mus i e submitted with your
information must be substantially the same as that provided here. Befo a rvq
cord must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left iron(, left rear, I ft sid of house Right front, right rear, right side of house.
forms on the
computer, use
only the tab key Address u J� a
to move your l.i
cursor-do not Cit /Town State Zip Code
use the return y
key. 2. System Owner:
Name
t
' Address(if different from location)
City/Town State ) ) p C de
Telephone Number
I
i
I
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ] Cesspools) eptic Tank p Tight Tank
Ej Other(describe):
4. Effluent Tee Filter present? [ Yes _ No If yes, was it cleaned? p Yes [ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati re contents were disposed:
.L.S Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
1
Commonwealth.of Massachusetts
City/Town of
System Pumping Record
Form 4
i
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
computer,use y ro
When fillip out 1. S ste Loc ati
forms on the
P
only the tab key Address _
to move your ° � t C°"`
cursor-do not CityfTown
use the-retug Zip Cade
rn State
key.
2. System Owner. ,p ECEIVED
Name
Address(if different from location) TOWN OF NORTH
» T ANDOVER R
T l "ALfy fCaThN
CityfTown State - Zip^- de'
Q.
�;
Telephone Number
-1. Pumping Record
1. Date.of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe)`
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. S st m Pu ed B ;
:'Name Vehicle License Number
.w
Company"
7. Locati Where conte� erei
sed::
Signatur of auler ~
Date
h.ttp://www.mass.gov/dep/water/`approval8/t5forms.htm#inspect
t5form4.doc-06103 System'Pumping Record•Page 1 of 1
I
w
TOMW OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & AI➢DRI+'ASS SYSTEM LOCATION
(example:left front of house)
DATE QII+'PUMPING: QUANTITY P ED : �� G DNS
CESSPOOL: NO YES SE PTIC TANK: NO YE S
NATURE DT SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
CD®D CONDITION I+7ULL TO OVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LE ACIMEi LD RUNBACK
EXCE SSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER R(E L
SYS E m PumPED BY: Bateson Enterprisesg Inc.
COMMENTS:
NTS:
CONTENTSTRANSFIERRED TO: .L. . Lowell Waste
i
1
i
TO�VN OF
SYSTEM
SYSTEM W7 EIS& ADDRESS SYSTEM LOCATION
C (example: left front of house)
at
DATE OF PUMPING: �( QUANTITY PUMPE D : GALLONS
CESSPOOL: NO
YES SE PTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
It
HEAVY A BAFFLES IN PLACE
ROOTS LE ACHFIELD RUNBACK
E XCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHE R(EXPLAIN)
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
NT'S:
i
CONTENTS 11UNSFEMED TO: BL. Lowell Waste
i
j
i
f
y�r
{�14
NO;\TN Ar� D0 �rr�
iA
SYST M. PUMTINC 'CC
�1
!',E hi U:WN R & hl?E��CSS SYSTEM I.O AT T, -7
Y'
\�1 L
(�VaNTiTY P _
(_i ��IrUU� rt0 oil. YCS S6fTIC' Ta��K r,G
N OUttO OF SERY,.LCG ANTME EMERCe vCr
(' YAT� Q N�
;TS� L� �`�; LEnCNF�ChG
�Z�.O
'. `,.` GXCESSI�YE $�Q111�D.S ' F1,000Cp _--
r !�
1 r 1�1 '���1 , t�,�{Iti jell%iY ii� �� r 1 I r, •.
TS
`.,U 11M G� "
th ( r t
j
!
TOWN OF NORTH ,ANDOVER
SYSTEM PUMPING P ECORD
I
' • M 0 WN E R & ADDRESS
:,L z
t',Xo3fT'I
/ }4 "
v"! E OF PUMP(NC f s " 6 QUANTITY PUMP[D/�,-
1
�� I'UUL NO "" YES SEPTIC TANK : NO YES
i
O'URE OF SERVICE: ROUTINE , EMERGENCY
� i !-IZV :vTIONS
GOOD CONDITION _ FULL '1'0 C0VLit
HEAVY CREASE BAFFLES IN I'L,,vC1":
ROOTS LEACHFIELD RL'NUACK _
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OiIiHER (EXPLAIN) —
ILM PUMPED BY : i��'r �� Y� _ ''�!., , �
I Nl FN TS:
u � I I.'N I'J TIZANS'FEIZRED TO:
I
t
r
Y
f
A14(4h Alvwver .6. 4. T s SEPTIC TANK sERVzcE
)fib s�Gin S�; 47 RAILROAD STREET
BRADFORD, to 01835
lbl4, I Liz- 15/ -izb 14 978-372-7471
MOM'S OF O c f6 b e,j_" � o
MONTHLY REPORT FOR TOWN OF d Y1Nye
DATE ADDRESS C%A=NS ~- C244mm
1®°3- ia c_ky rico L.
bo 3 lv O/YMM / lc /cihe
l000
fDom' jq FO3+r-- 5..t" 1
�a L166 win k r
10�-� �'l � %e�► r c /ern � — /boo
6-6 °796 006
L) iu
16 (v 41?
60 0