HomeMy WebLinkAboutSeptic Pumping Slip - 1116 SALEM STREET 12/9/2015 I[ N
TOMIN (�►E rNOR.TH AND OVER,
s
SYSTEM PUMPING RECORD
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AU"" 41 SYS'tEN OWNER&ADDRESS SYSTEM LOCATION
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(example: left frodt of house)
lip
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DATE OF PUMPING« l —0 QUANTITY PUMPED J.�C GALLONS
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CESSPOOL: NO YES SEPTIC TANK: NO YES
0"i,
j'" NATUR OF SERVICE. `� ROUTINE '
". EMERGENCY' �Ar
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Ulf"
f
� �"eE� x r y,( r�,
et�i y � t�W„i, ” GOOCONAITIONr;;'
FULL TO COVER
HEAVY GREASE
BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK —
t EXCESSIVE SOLIDS FLOODED
fi
SOLIDS CARRYOVER
OTHER (EXPLAIN)
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d *1Ci+� ` `� ,;fir $ STEM'rPUMPED BY:
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L A T TS, RANSFERRED TOE.
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TOWN OF
SYSTEM
DATE: -'
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
DATE OF PUMPING: 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 R(EXPL
SYSTEM PUMPE,D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
I
TOWN OF Altluld
SYSTEM PUMPING RECORD
DATE:ILLU A� RECEIVED
0
TOWN OF NORTH ANDOVER
SYSTEM OWNER& ADDRESS SYSTEM LOCATION HEALTH DEFAN�R=N
(example: left front of house)
(06
DATE OF PUMPING: QUANTITY P ED : � � GALLONS
CESSPOOL,: NO YES SE PTIC TANK: NO YES
NATURE OF SERVICE: RGUT EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIMELD RUNBACK
EXCE SSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O IL(E L,
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED T®: .La a Lowell Waste
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. Syst m Location:
forms the
computer, use
only the tab key Address
°
cursor edo not
use the return CityfTown State Zip Code
key_ 2. System Owner:
Name
Address(if different from tocation
Cdyfrown State
Telephone Number
B. Pumping ReGOrd
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 If yes, was it cleaned?
E] Yes ❑ No
5. Condition of System:
�J
6. System Pumped ray- P'
Name Vehicle License Number
Company
7. (vocation here contont ere osed::
Signatur of ul Date
http://www.mass.gov/dep/water/approvals/t5forms:htm#inspect
t5form4.doc.06103 System Pumping Record•Page 1 of 1
1\U
i
® monwe lth ®f s� Chin tts
City/Town of _ RECEIVED
. .....�.a
Form 4
l
s DEP has provided this form for use by local Boards of Health. Othe fo� urrro `) p
information must be substantially the same as that provided here. I -using-this°forrrr°z 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: _ Y
When filling out 1. Syste Location:
forms on the _
computer,use
only the tab key Address
to mane your
cursor-do not Citylrown /' State Zip Code
use the return
key. 2. System Owner: -
VQ Name
,n Address(if different from Nation)
City/Town State p Code
Lt 7
Telephone Number
B. Pumping cor
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) -[D-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes,G No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped B
Name Vehicle License Number
�, _.w_.
Company M
7. Location herq cont pts a disposed:
4
Signatu of a er Date
I
t5form4,doc•06/03 System Pumping Record a Page 1 of 1
Commonwealth of Massachusettswa.
i
City/Town of
�0�,u „
System a
Pumping Record_..
OF
Form 4 rr„v/V i r,ica��i I r-c NI�C) F”
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: r'°
When filling out 1. System Location: Left front, eft rea , left sid of house..,�tight front, right rear, right side of house.
forms on the
computer, use
only the tab key Address
to move your t ( 7 ✓ ( {`. � �rf
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
w
- — Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
It
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: Cesspool(s) Septic Tank p Tight Tank
Q Other(describe):
4. Effluent Tee Filter present? 0 Yes 0----No If yes, was it cleaned? El Yes ( No
5. Condition of System:
I �
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
AureLowell Waste Water
r Date
t5 form4.doc•06/03 System Pumping Record•Page 1 of 1
I
' J
PAGE II STEWART'S SEPTIC TANK SERVICE (CONT'D) 1
04-22-96 A 31 STONE CLEAVE ROAD 1,800
201 BRADFORD STREET 11000
04-23-96 585 BOXFORD STREET 1,500 HEAVY
A 175 GREAT POND ROAD 2,000
04-24-96 1615 OSGOOD STREET 500 FLOODED
.A 122 OLYMPIC LANE 1,500
A 1116 SALEM STREET 750
04-25-96 A 75 FORREST STREET 11000
04-26-96 550 BOSTON STREET 2,000 2-1,000 TANKS
04-27-96 A 1015 JOHNSON STREET 11000
175 FOREST STREET 11000
350 SHARPNER'S POND ROAD 1,500
04-29-96 A 18 STEVENS STREET 1,250
A 100 FOREST STREET 1,500
A 82 PADDOCK LANE 1,500
04-30-96 A 133 SUMMER STREET 11000
A 347 HILLSIDE ROAD 11000
Commonwealth of Massachusetts
City/Town of
System Pumping cr
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 al Righojjjf house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear(if building, Under deck
Address ` �I �r'� c.� t� ��'�„✓lam^` ,, c:.,..� ���� �.
City/Town r State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zi p Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
er(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio of System-
PLAAP
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lac ion ere contents were disposed:
G L S. Lowell Waste Water
SignAtufe OauleV Date
I
t5form4.doc•06/03 System Pumping Record•Page 1 of 1