HomeMy WebLinkAboutSeptic Pumping Slip - 1264 SALEM STREET 12/9/2015 Commonwealth of Massachusetts
J
City/Town of
d
Sys' tem Pumping Record
Form 4 ,�
m
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 house, Left Al
Igh ide of house , Left/
Right side of building, Left/Right front of building, Left/Right rear of building,--Under dec
Address '� p
Citylrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown Stat
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped:
Gallons
3. Type of system. ❑ Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If es was it cleaned?
Y � ❑ Yes ❑ No
5. Conditio o System-
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
4eHaule Lowell Waste Water
S Date
t5fomti4.doc•06/03 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MA A U TT
System Pumping Record
_ Form 4 i:VU f 61ii.�C1b j
DEP has provided this form for use by local Boards of Health. The Syst ml- i 0,ir�g �tedl i 'U6t
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 2 b v
only the tab key Address
to move your zo
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name
rerun .-
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes 9No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By, ( �
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
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I
TOWN GE aLLimler 2
SYSTEM PUMPING RECORD � �
DATE: .
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
�4ww)-\'- (example:left front of house)
' (-�
Ova-
C
DATE OF PUMPING: `( C) QUANTITY PUMPED : 1 `t GALLONS
CESSPOOL: NO YES SEPTIC TANK; NO YI;S
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)
sYsum PUMPED BY; Bateson Enterprises, Inc.
COMMENTS:
�r
CONTENTS TRANSFERRED TO: >
Commonwealth of Massachusetts
N1 0
m
��o^��/ � \]
�� o ^�vnxx v�o ~�
System Pumping Record
"JUN
Form 4 TOWN OF NORTH AND VER
EHEALTH DEP,�ART ENT
DEP has provided this form for use by local Boards of Health. Other forms may be use
information must basubstantially the same em 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 or-ottier approving authority.
A. Facility Information
1. System Location: Left side of houo m. Left front of hnuoa. Right front of house, �
Left rear of house, Right rear of house. Left rear of building. Right rear of building. �
Address
Cityrrown State Zip Code
2. System Owner:
Uv_ ss`-- \
Name
Address(if different from location)
City/To un
Telephone Number
B. Pumping Record
1. Date ofPumping 2 Quantity �
Date � � Gallons
3. Type ofsystem: I El CesapVVKs) c^'�oUoTmnk El Tight Tank
[l Other(describe):
4. Effluent Tee Filter present? [] Yes Glqo |f yes, was itcleaned? E] Yes 0 No
5. Condition
G. System Pumped By:
Neil Babeson F5821 �
Name Vehicle License Number
-
8abason Enterprises Inc /
Company
. Location
mfom4�mrUO�o
� System Pumping Record`Page 1m1
i
t.'0111111ollwV lth of Massachusetts
.
Masgactlus trli
pulp
i
I
System Urvner System Location
C-M
t
Date of Pumpinf;: a � Qoailtity Pumped: ti caUorls {
J,
Cesspool: No ( Yes Septic Tank No Yes . w.
System Pumped by: c°greo0a off& me4 License
Contents transIbrrred to : Te ter wrenc St 1 I tract
Date: inspector; _�
I
Commonwealth of Massachusetts
U
City/Town of
System Pumping Record ` °` 2 �
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used but the 1
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-eft/Riglrear 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. System Owner: I
c'-- (A, l
Name
Address(if different from location)
City/Town Stat (� � t �� Zip 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
Condition of System:
5. on `
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company ,
7. Location where contents were disposed:
G L S i Lowell Waste Water
IaA.
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1