HomeMy WebLinkAboutSeptic Pumping Slip - 62 BANNAN DRIVE 12/18/2015 v G.^ ,rdf wisl�lJ4W IMir
Commonwealth of Massachusetts RECEIVED 1
W City/Town of
w° S stem Pumping Record
Form 4 .��VVN�L d�� � o w j Aj m): a w�ARI
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 ight side of hoes, , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under r3eck
Address
Cityfrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown ' State code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o 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. Locatio here contents were disposed:
_L S. Lowell Waste Water
T_
fy
Signitufe 9t Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
Commonwealth of Massachusetts
= City/Town of
W° 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/Right rear of house, Left/ i ht side of housib, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under ec
Address r
Cry C J 1C)
Cityrrown State Zip Code
2. System Owner: i^
Name
Address(if different from location)
Cityrrown ' State f, Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date - Gallons
3. Type of system: ❑ Cesspool(s) [3—Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ 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 v here contents were disposed:
`{GLL S. . Lowell Waste Water
Sign t e 9t Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
i
1
Commonwealth of Massachusetts
City/Town of
System 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/ t sid;ec f hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under
Address /� A TTYI'l City/Town State Z0'56d
2. System Owner: AUG �'
Name �vlTMENT
Address(if different from location)
CityJTown State Zi 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:
oCKA
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
lignitufe kHaule Lowell Waste Water
t Date
t5form4.doc•06103
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping cr
Form 4 °
'rowwN of NORTH ANDOVER
DEP has provided this form for use by local Boards of Health' se , 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 front of house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
,..,
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State - _ Zip Code
4
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped Gallons
3. Type of system: ❑ Cesspool(s) [T Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑'110 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
- 6��)'/")f
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locationwrt ere contents were disposed:
Q.L.S. kiwell Was Water
zz
Sig t of uler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of ����. ������������������
a
System Pumping Record IINroaM, mu ' n
Form 4
k
bEP has provided this form for use by local Boards of Health. Ot e, 1 �.. the
information must be substantial) the same as that rovided here. Be I �� "� �t"C ck with our
Y pr . . 4� qlfi� Y
local Board of Health to determine the form they use. The System t 'ffig' submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of hou e, Right side of house, L ft front of house, Right front of house,
Left rear of house, Right rear of ho -Left rear-of-W-]ding Right rear of building.
Address
&Aj r'A1\'\ 4-
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State , ip�Code
Telephone Number
B. Pumping Record
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 ❑-Nb If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson 175821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationy�ttr`e�}e contents were disposed:
L . �% Lowell Waste Water
NL-"-, -- �_._.c
Ygrptute of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
N Commonwealth of Massachusetts
City/Town of 711 FE
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of
b----rffiiW&b9 sed, but the
.Oh
information must be substantially the same as that provi j,lf� i orm, check with your
'8
local Board of Health to determine the form they use. Th Y§f6m'—P"u' mping 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 re, r, right side of house..
forms on the
computer, use
only the tab key Address
to move your Ak
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
de
City/Town State hone C
C
p I L,
Tele Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) [_J--SWic Tank [I Tight Tank
Other(describe):
4. Effluent Tee Filter present? Q Yes B-11C- If yes, was it cleaned? [I Yes [j No
5. Condit' n of System:
�a
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatiojLwhpre contents were disposed:
L.S.D Lowell Waste Water
tignalu-re of H u r Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
1
i
Commonwealth of Massachusetts
_ City/Torn of i
a System Pumping Record
a, sa
Form 4 `PQC7
J
DEP has provided this form for use by local Boards of Health. Other forms mayf ba,uss�d,,but tit f
information must be substantially the same as that provided here. Before 9 sir this form,eheck°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:
p
forms
use �. \ (_., �,. �_,' s� :.
only the tab key Address ..�.,) 0
to move your C:� G
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
VQ Name
r Address(if different from location)
City/Town State Zip Code
CS-
Telephone Number
B. Pumping ecor
1. Date of Pumping ®ate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑,-Septic Tank ❑ light Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑-No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
w.
6. System Pumped By:
Name Vehicle License Number
Company
7. Location ere contents were disposed:
A/LeA
Sigr(at46 o Hauler Date
t5form4.doc•06/03 System Pumping Record o Page 1 of 1
l
Colmmottwealtll of Massachusetts
0 , A r, --ll Qr . , Massachuset(s
I
I
f
System ' o ira_ Record
System Owner System location
- .A 1 .. ..
Date of 1'111111in r:
� � ( ( ' ),gc)1,7 Cpuailtily Pumped: �� D 0 6 gallons
Cesspool: No Yes Septic Tai k: No Yes �
System Pumped by: varedea grf Taa license #
Contents transferrred to : Greater Lawrence anftary Vlstrlct
Date: _ T_ Llspector:
t;'omll nave �,Itlw of Massachusetts
Massachusetts
t rr>t P�urrnPit) _f�ec�►rrl
System Owner System Location
Uate of l uulpin�y t Quairiity Pumped: �'�„ gallons
,
Cesspool: No - Yes Septic Tack: No Yes [`4"_
System Pumped by: etr aca gfircrh4ma License #_v--
C'onteuts transferrred to : Greater L.ewm Ce 9,eDltr�rv_r�iatrict
Date; _____ ___ Inspector:
yr,