HomeMy WebLinkAboutSeptic Pumping Slip - 78 VEST WAY 12/3/2015 Commonwealth of Massachusetts
u 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/Right front of house, Left/ f1gtir o izus , Left/ ddb 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. System Owner:
Name
Address(if different from location)
Cityrrown St 7t ; Code
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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
E)
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 Haule Date
t5form4.doc-06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
u City/Town of 6elfi
System Pumping Record ANDOVER rOWN Form 4 l
i
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/Right rear of hous , e /right gl"�f'ho-use /
Right side of building, Left/Right front of building, Left/Right rear o llding, Under deck'
Address
City/Town State Zip Code
2. System Owner: ❑� �� � �
Name
Address(if different from location)
City/Town State p Code
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 EYNo If yes, was it cleaned? ❑ Yes ❑ No
5. Canditi of,System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location�w, re contents were disposed:
.L'S. Lowell Waste Water
Ilia
Sign toe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth ^�� ��
7--W�\\
REICEIVED
`������������noon �,^ mnoassachusetts
City/Town of ~u
System Pumping Record Ov
TOWN OF NORTH ANDOVER
Form 4
7HEALTH DEPARTMENT
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 ha submitted to
the|oum| Board of Health or other approving authority.
A. Facility Information pe�
I. System Locati Left side of hous�-e),' Right side of house, Left front of house, Right front of house,
ou
'�-�buse. Left rear of building. Right rear of building.
Left rear of house,
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town state
Telephone Number
'
B. Pumping Record
'
1. Date cnPumping 2. Quantity
um« � Gallons
3. Type nfsystem: [l Cesspool(s) B'SepticTank Fl Tight Tank
El Other(describe):
4. Effluent Tee Filter present? E] Yes R�No |f yes, was it cleaned? F� Yes 0 No
5. Con tio of System \ /
MY �MA
8. System Pumped By:
Nei| Bmbason F5821 �
"~"~ Vehicle License Number
Bateson Enterprises
Company
7. Location where contents were disposed:
Date
t5form4.doc-06/03 System Pumping Record-Page I of 1
I
RECEIVED
mmmwmwwuwwiiiiiiii j
Commonwealth of Massachusetts
City/Town of
System Pumping Boor MAY 2 6 2009°-,
Form 4 O"0`4 OF NORIFH ANDOVER
l.,lhAi'TH D P/&RrM EM ` w
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. System Location: Left front, left rear, left side of house. Right front, right rear ght side of house.
forms on the _
computer,use
only the tab key Address �j r
to move your
cursor-do not
use the return City/Town tate Zip Code
key. _ 2 System Owner: 1
Name
Address(if different from location)
Cityfrown staR,,�� Zip Code
Telephone Number J
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) eptic Tank [j Tight Tank
Other(describe):
4. Effluent Tee Filter present? Q Yes o If yes, was it cleaned? p Yes No
5. Condition of System:
V I61
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati where contents were disposed:
L.S.D Lowell Waste Water
I C19
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth ss hus is
City/Town of
System cr
Form 4 P(:�JV u rSV- N��RI H/00()V ER
DEP has provided this form for use by local Boards of Heal .6ther fclrlrt tYt tIW,W but the
information must be substantially the same as that provid lWre.'Bel�ore using this form,check with your
local Board of Health to determine the forrn 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 _ t f � ° " 4; �' '
forms on the
4 "
computer, use
only the tab key Address ,..
to move your
cursor-do not
use the return Citylrown tate Zip Code
key. 2. System Owner:
Name
man Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping co
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? El Yes I dfrto If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. SystT�7 By.
Name °° Vehicle License Number
Company
7. Location her Conte is we sposed:
-
Signatur of a er Date
i
t5forrn4.doc^06103 System Pumping Record•Page 1 of 1
I
I
i
STEM PU ICI RECO
MAY 2 5 2
DATE:
OF ted()RT W E A 1Ckl DVE
lf�l C1N
SYSTEM OWNER & ADDRESS SYsTEM LOCATION
(example: left front of house)
VU k/ c �
DATE OF PUMPING: Qu ITY P ED : [ 5 C GALL S
CESSPOOL: NO EPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINEE EMERGENCY
OBSERVATIONS:
OD CONDITION FULL TO COVER
AY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTBE R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprisesg Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S Lowell Waste
1
I
i
i
TOWN OF
SYSTEM PUMPING aK , ,
DATE:
011,5urmw......Jaffll
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
p
�* riuwrw
j
DATE OF PUMPING4 QUANTITY PUMPED : :a " ' GALLONS
CESSPOOL: NO " " YES SEP'T'IC TANK: NO YES
NATURE OF SERVICE: ROUTINE . .µ EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises,riSCS, Inc.
COMMENTS:
CONTENTS TRANSFERRED To: .L. . Lowell Waste
I
ANDOVER TOWN OF NORTH
SYSTEM PUMPING
DATE: C
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
Vwc ,
DATE OF PUMPING: r _ QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: )cl e".kk
COMMENTS:
CONTENTS TRANSFERRED TO: ,
Commonwealth of Massachusetts
Massachusetts
_System Pumper Record
System Owner System Location
�7 V -�
Date of Pumping: Quantity Pumped: gallons
Cesspool: No Yes ❑ Septic Tank: No ❑ Yes
System Pumped by: veradoo ct License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector: