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Home My WebLink AboutSeptic Pumping Slip - 11 BARCO LANE 12/18/2015 Commonwealth of Massachusetts 2 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 tarrie 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 of house 1. System Location: Left/Right front of hour ej;ii,;Rigllr"r� Leff/right side of house, Left Right side of building, Left Right front of building, Left/Right rear of building, Under deck Address 0111C zz� City Fawn (A' state Zip Code 2. System Owner: �0"'\ Name'\Ij Address(if different from location) CityfTown State Zip Code Ir ur Telephone Number lei OF p4or)VER 0 e.h mr B. Pumping K4d6ed -"m"'- 1. Date of Pumping Date 2. Qua ptity'Pumped: Gallons 3. Type of system*. E] Cesspool(s) n--Septic Tank r❑-1 Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yap B- o If Yes,was it cleaned? ❑ Yes r-1 No, 5. Condition Sy em: VA,,_ 6.- System Pumped By: Nell Bates7bq F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatig"Wip- ontents-were disposed: 7 Lowell Waste Water -stgwitufe cf HauleV Date t5form4.doc•06103 system Pumping Record•Page I of 1 Commonwealth of Massachusetts City/Town of I System Pumping Record 1 r` 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 f� cl ,9K with your local Board of Health to determine the form they use.The System Pumping Record`mus be(,submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/Right front of hous�et2lgh ar o_ f how, Left/right side of house, Left/ Right side of building, Left/Right front of�if�lfng,Left/Right rear of building, Under deck 9 Address �, �7 _ � City mown State Zip Code 2. System Owner: Name' Address(if different from location) Cityrrown State ip Code r� .. � ;-- Tele one 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 M' No If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition 7f S stem: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water V/0))- signitule cf Haule Date t5form4.doe-06/03 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts City/Town of �XAU H DE PART UIT 1 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, a Righ ear ofhous Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address _ Ncy City/Town State Zip Code 2. System Owner: f Name Address(if different from location) CityrTown State ry C 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 3No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of S stem: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company . 7. Loca i_nwhere contents were disposed: G L S Lowell Waste Water —07 � Sign to a Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts NO R00V D7 City/Town of :R En'F 0 1 7VE D- System Pumping Record 4 1 Form 4 R '14 Z 0 1?, P DEP has provided this form'for use by local Boards of Health. Oth e j a N h k with your efdt6tti information must be substantially the same as that pro ftn" 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 Mji7gtt rear ofliQusd, Left/right side of house, Left Right side of ' buildin Left/Right front of building, Left/Right rear of building, Under deck Xxx Address )Q - -6t—yrrown state Zip Code 2. System Owner: Name Address(if different from location) cityrrown -§t—al—e Zip Code Telephone Number B. Pumping Record '-( "1 2, 2. uantity Pumped: 1. Date of Pumping Date Gallons 3. Type of system: ❑ Cesspool(s) � eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? EO] Yes No If yes, was it(cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location whet contents were disposed: Lowell Waste Water —G.L�j Lowell Waste Water Sign to e Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of I Commonwealth of Massachusetts RECF.IVED D "'mF "V City/Town of System Pumping Record I AV Al Form 4 0 ORTHANDOVER TOWN 0 F N MT R JL�j , P ENT DEP has provided this form for use by local Boards of Health. Other forms p 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. Systenj.Loc%ion: Left front of house, right front of house, left side of house, right side of hous4lp rear of holu"s—'fight rear of house, left side of building, right rear of building, under deck. C City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State 'zp Code > Telephone Number B. Pumping Record 2. Quantity Pumped: Gallons 1. Date of Pumping Date 3. Type of system: ❑ Cesspool(s) ffjSeptic Tank ❑ Tight Tank F-1 Other(describe): 4. Effluent Tee Filter present? ❑ YesEt"'No If yes, was it cleaned? ❑ Yes ❑ No 5. Cond f System: r7 � �� 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. -Company 7. Loqation, here contents were disposed: .L,S.D' L ell Waste Wat 0 Signature of a r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of V° 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 Important: When filling out 1. System Location: Left fror rleft rear, ft si of hous". fight front, right rear, right side of house. forms on the computer,use only the tab key Address P � /f ,/�„ / Jf � to move your `` � ® �/ 4ZA- cursor-do not City/Town State Zip Code use the return key --- 2. System Owner: Name Address(if different from location) City/Town Sta !3D(S Zip Code,, Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 8 Cesspool(s) Septic Tank Ej Tight Tank Ej Other(describe): 4. Effluent Tee Filter present? Ll Yes o If yes,was it cleaned? p Yes No 5. Condition of System: n �� "'-a� 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location wh ontents were disposed: .L.S.D Lowell Waste Water igna ure of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth ®f Massachusetts City/Town of System Pumping Record JAN Form 4 V form for use b local Boards of Health. Other �nan rri, taw ,-bti-tlf DEP has provided this f y 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: " forms on the ,r ": .... .. •-.' computer,use only the tab key Address v .. a r' to move �' �°r^ �. �' z m T C cursor-do not Citylrown State P ode use the return key. 2. System Owner: -_ Name � Address(if different from location) Citylrown State Zip Code Telep one Number B. Pumping Record 1. Date of Pumping pate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): ✓ 4. Effluent Tee Filter present? ❑ Yes 0-00 If yes,was it cleaned? ❑ Yes ❑ No 5. Condition System: 6. Syste Pu By: Name Vehicle License Number (2 z A Company 7. Locatio he ontent ere Is osed: Signatu of ul Date t5form4.doc•06103 System Pumping Record o Page 1 of 1 Commonwealth of Massachusetts City/Town of y tem ump�in cord U Form 4 -i-O FN OF NORTH ANDOVER HEALTH TH DEPART ENT 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 tl0n form on the - s . When fillip out System oca only the tab key Address C to move your cursor-do not use the°retum Cityfrown sta e Zip Code key. 2. System Owner: ' I Name Address(if different from location) Cityrrown State t ode` Telephone Number B. Pumpin.g Record 1. -Date.of Bumping Pate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank- ❑ Tight.Tank ❑ Other(describe)` 4. Effluent Tee Filter present? ❑ Yes ❑'1Go If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of S Y stem: VA o( k�U�J t W 'k-63-CAk,'47Z.- 6. Syste�Pumped BY: Name Vehicle Li Number Ck Company r is 7. Locatio here contents e d Signatud of Wule. ate h,ttp://wwW.mass.gov/dep/Water/poptovalt/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record-Page 1 of 1 i i TOWN OF V '� .mww P w 4,. kil¢ iiuP' DATE: b,31 3 Z009 SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of Douse) (A -_ ' GALLONS DATE OF PUMPING: � �T:. `° QUANTITY PUMPED : GALLONS CESSPOOL: NO YES SE PTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: FULL TO COVER GOOD CONDITION BAFFLES IN PLACE HEAVY GREASE ROOTS LEAC ELI)RUNBACK FLOODED EXCESSIVE SOLIDS FLOODED SOLIDS C YOVE t 4 II(EXPLAIN) SYSTEM P EJ D BY: Bateson Enterprises, Inc. COMMENTS: CC9NT'1JNT's TRANSFERIZED TO: .L. Lowell Waste I SYSTEM AQ),vie L TOWN OF -L/, � I DATE: *. �?) SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) H F ..� 0 . DATE OF P ING: fl -� QUANTITY PUMPED : 0 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 LEAC LD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PumPED BY: Bateson Enter IriSCs9 Inc. COMMENTS: CONTENTS TRANSFERRED TO: ) . TOWN OF NORTH ANDOVER '`"A SYSTEM PUMPING RECORD DATE: , SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) t DATE OF PUMPING .z QUANTITY PUMPED i r 0 .1) GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES �J NATURE OF SERVICE: ROUTINE v/ EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) w.� SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: �'� i I TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER i 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 (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: ('011111101"Vepith of Massachusetts 1 Itl15 gM j t rT� i Record System Owner System Location Date of Pumping: C) r` Quaittity Pumped: `` `� gallons Cesspool: No Yes Septic 'Tank: No Yes �- System Pumped by: geteej®g 5ff ftijej License # Contents Uansferrred to : Great lct llate: _ b1spector' FORM - SYSTEM PLTMPL\G RECORD Commonwealth of Massachusetts , Massachusetts system Pumping Record 'stem Owner Systern Location �� 1 r Date of Pumping: t — °°� Quantity Pumped: (gallons Cesspool: No Yes ❑ Septic Tank: No ❑ Yes System Pumped by: �� e-'�� License #: Contents transferred to: Date Inspector