HomeMy WebLinkAboutSeptic Pumping Slip - 1276 SALEM STREET 12/9/2015 Commonwealth of Massachusetts °
City/Town of
System Pumping Record
Form 4
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:
When filling out 1. Syste Locati
forms on the
computer,use
only the tab key Address Sl to move your �r _, ,. l"__ Aki
cursor-do not
ty/Town Stare
use the return Ci
.key.
System tem Owner:
Name
iW µ
ut'
Address(if different from location) I �Y
CityfT'own State w
Zi Code
PT�1` ��
Telephone Number
B. Pumping Record
1. Date-of Pumping Date 2. Quantity Pumped: "
Gallons
3. Type of system: Q Cesspool(s) Erseptic Tank- ❑ Tight.Tank
❑ Other(describe)`
4. Effluent Tee Filter present? E] Yes Ej No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: r v
6. System Pumped By:-
�
'Name . f Vehicl.e Liven§e Number
Company -
7. Location w ��e contents.�e d's
e d:
C° p,
- �
K ( ._
Signat e a ler _ Date
http://www.mass.govldep/w er/.pprovals/t5forms.htm#inspect
k5form4.doc•06103 System Pumping Record•Page 1 of 1
i
Commonwealth ofMassachusetts 1
t
t
v uappj Record
System Owner System Location
L _. � ..�
Date of 1"umping: Quantity Pumped: � ��� ° 'gallons
Cesspool: No Yes Septic Tank: No U Yes
System Pumped by: varedere 4 ftija License#
Contents transferrred to : Greeter Lawrence QenitarV Plstriet
Date: _ T_ — Inspectors
I
Cot trto711eatih of Massachusetts J
, C Massachusetts
gjoLem ul" 11n Record
System Urvner System Location
Date of 'tntping: Q uairth Pumped:
Cesspool: No (. w Yes LJ Septie Tank: No U Yes
System Pumped by: St'f'edorc License#
Contents translerrred to ; Greater a ce 8e ttta► l;xtrlct
Date: _ Inspector;
TGBtM OF N('iw°I lAND"�"�
APR °� �
N"
Commonwealth of ssachusetts
Massachusett
NOV ..
PLlH�
System i1 r ..,_
System Owner System Location JA L(k(k kl tA
Ct
Date of Pumping: Quantity Pumped: 1 506 gallons
Cesspool: No [ 'Yes [] Septic'Tank: No [] Yes [4/
System Pumped by: 4 License #
Contents transferred to: Greater Lawrence Sanitary 1 trl
Date: 1 f Inspector:
i
i
Commonwealth of Massachusetts
Massachusetts
System Pumina Record
i
System Owner System Location
n allons
Date of Pumping, Quantity Put ped a
w1: No Yes ❑ pj : No ❑ Yes
System Pumped by: ct,Pct License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector:
NOV TOWN OF
1 Y)
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER.& ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF P ING: _ �b QUANTErY PUMPED : 1 C GALLONS
CESSPOOL: NO YES S PTIC TANK: NO YES
NA OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELDRUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER 'OTHER(EXPLAIN)
SYSTEM PUMPE,D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS
SFE +D TO: .� C
Commonwealth
`����������h����nu / �^/
City/Town of
Ft F-
System Pumping Record I A Y ?5 Z70 I0
Form 4
1 I-OWN OF NORTH ANDOV%R
DEP has provided this form for use by local Boards of Health. Ot r W-w Fbwm rbu the
information must be substantially the same as that provided here.Eeioie using t is 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. house, Right side of house, Left front of house, Right front ofhouse,
Right rear ofhouse. Left rear ofbuilding. Right rear cfbuilding.
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City[Town '-Zip Code
Telephone Number
B. Pumping Record
�
1. Date ofPumping 3� Quantity �
_-- Gallons"
3. Type nfsystem: F1 Cesspool(s) cTank El Tight Tank /
L1 Other(describe):
4. Effluent Tee Filter present? U Yes Er-No |f yes, was it cleaned? Fj Yes E] No
5� Condition of
G. System Pumped By:
Nei| Boteaon F5821
Name Vehicle License Number
Bateaon Enterprises Inc �
Company �
�
7. Location where contents were disposed: �
Lowell Waste Water
�igrptute of HaulVr Date
t5mrm4.doc^0003 System Pumping Record`Page 1of1