HomeMy WebLinkAboutSeptic Pumping Slip - 32 BANNAN DRIVE 12/18/2015 Commonwealth of Massachusetts
1
City/Town of RECEIVED
h.
S i t in or
y �
AY `e 1 7015
Form 4
DEP has provided this farm for use=by local Boards of Health. Other forms may t &6 �bist thiP
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 tgli�rear o�"uhou e Left/right side of house, Left/
Right side of building, Left/Right front of building, Le Ig rear of building, Under deck
Address
Nr .
City/Town State Zip Code
2. System Owner:
Name*
Address(N different from location)
Citylrown State Zip Code
Telephone Number
j
B. Pumping record
1. Date of Pumping �-� 2. Quanti Pumped:
Date ty Gallons ,
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Syste . G/
LA
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati ere contents were disposed:
GLLS-P Lowell Waste Water
C --
Sign a Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
` I
Commonwealth
�����������Y�N���,�o , v�,
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System Pump~ng Record
Form 4 TOWN OF NOR'r�l ANDOVER
HEAL:rH DEPARTMENT
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
|000| Board of Health bo determine the form they use. The System Pumping Record must ba submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
rear cfU
_-_____�
/
City/Town State Zip Code
2. System C}vvnec
Name
Address(if different from location)
City/[own Otu *�� ��� Zip Code
�� �_��3—~ Li��``��
Telephone Number
B. Pumping Record
'6—07
i
1. Date ofPumping Date 2. Quantity Pumped. Gallons
3. Type ofsystem: Cesspool(s) ioTmnh El Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? [] Yes o |f yes, was iicleaned? Fl Yea E] No
5. Condition ofGystenn-
' O� System Pumped By:
Neil J. Bab*eon F5821
..a"." Vehicle License Number
Botaaon Enterprises |
Company
y Lo �
Signature of Hole( Date
0form4dou~0003 System Pumping Record^Page 1of1
Commonwealth lth 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/ ht rear 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 c
City/Town State Zip Code
2. System Owner:
t
Name'
Address(if different from location)
Citylrown State Zip Code
Telephone Number
u„
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons -r
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of System:
Uk-kA �0
6: System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inca �x p
Company DEC �, J 4
7. Locatio h contents were disposed:
ji -S. Lowell Waste Water
Haule Date
t5form4.doc•06/08 System Pumping Record•Page 1 of 1
i
m
ED
Commonwealth of Massachusetts
City/Town of SF.,
System Pumping in� 9 ecord Tip OF NOKrH ANDOVER t
Form 4 l l ..„r PAF�1 µNI
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 tj§6 h ear 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 A
City town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
6ASr � 1
Telephone Number
B. Pumping Record
1. Date of Pumping < - 2-q r (r 2. uantity Pumped: I (>
Date Gallons
3. Type of system: El Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2�No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: 11
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wb re contents were disposed:
G.L S. Lowell Waste Water
~ ' ' Q
Sign toe I Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
"T I ti ?C)'10
System Pumping Record (IL
Form 4 TOWN OF NORTH ANDOVOR
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other Zormsmayy e;use , u e
information must be substantially the same as 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-other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of houst!�, kj�'ht—re�6-r—of h�ous - Left rear of building. Right rear of building.
Address A,
City/Town State Zip Code
2. System Owner: ------
Name
Address(if different from location)
City/Town State- Zip Code
7/ -3( -3
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity'Pumped. Gallons
3. Type of system: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0---No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
P, am� V�'—
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ere-co tents were disposed:
=.LSD Low Al W e W2ter
Signature orHiulq Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
Commonwealth of Massachusetts ..R 11 E EI D w
W.
City/Town of
r
2 2,
System Pumping �o��...
Form 4
-K) r��ov- NOR 1H ANDO'VO�' i
p y
DEP has provided this form for use b local Boards of Health. Other forms
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 front, left rear, left side of house. Right fron<&d1f§a0ght side of house.
forms on the �y
computer, use
only the tab key Address
to move your ��
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
a{
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Cesspools) Septic Tank Q Tight Tank
Q Other(describe):
4. Effluent Tee Filter present? Q Yes M/�o If yes, was it cleaned? Q Yes Q No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
A 4Hu Lowell Waste Water
Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
1� f
Commonwealth ®f Massachusetts
City/Town of
System Pumping Reco r . z ��. I Form 4 DEP has provided this form for use by I I Bo6��i�o �Abtorms may be used, but the
information must be substantially the a as that provided herefore using this form,check with your
local Board of Health to determine the fo use.Thd. mping Record must be submitted to
the local Board of Health or other approv
A. Facility Information
Important:
When filling out 1. System Location:
forms on the + ..
computer, use
only the tab key Address r <
to move your c �; °� C` ,l,,a 1 Jv'.` /l0/✓1 ,
cursor-do not Cityrrowm State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town State R Zip Code
d�, 31
Telephone Number
Pumping B. cr
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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: qq
6. System Pu pfd By:
Name /° Vehicle License Number
Company
7. Location cont is w disposed:
65
�f 4�..*Y.w"'° .�'" ^^ a 1, �4v �y.^"M�'�,.... ✓7
-§Ignatufe ofiia6ler Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
i
PUMPING TOWN OF
EIVED
SYSTEM
Q 2005
DATE: TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: loft frout of house)
k1XI
DATE GE PUMPING: ��� QUANTITY PUMPEA D : � GALLONS
CESSPOOL: NO � YES SEPTIC TANK: NO YES
NATURE, GE SERVICE: ROUTINE EMERGENCY
OBSERVATIONS-
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LE ACHFIELD RUNBACK
EXCE SSIVE SOLIDS FLOODED
SOLIDS CARRYOVER ® R(E L
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
Cf! S:
CONTENTS S E D TO: ,L, , Lowell Waste
TOWN OF
j
VSY.El Srd. N! l R C 1
DATE: OCT h
19 200
"tiWld; &: �vEZd'T� � I11)f \/Ir,R.
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
left ouse)
'rout of h.�.,
r
> lw°
DATE i ewe 1Pi G;- t —c' r i iUA n i CV ?'Ki-ri-4,E) , GALLONS
CESSPOOL: i SEPTIC C 9'A fWK; Nib il-�S '
NATUrcE OF SERVICE: ROUTINE EAMERGENCY
OBSERVATIONS:
GOOD CONDIT-ION FULL TO COVER
HEAVY 43REASE BAFFLES IN PLACE
ROOTS LEACUFAIIE LD RUNBACK
EXC !',SSIVE SOLIDS _ FLOODED
SOLIDS CARMICYOVER 0-1 R(EXPLAIN)
SYSTEM PurvpfED BY. 11111a
COMMENTS:
TS:
TOWN OF
SYSTEM PUMPING RECDRD,
DATE: 9
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
Oc tA
v
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(EXPLAU-4)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED To: G.L.S.D Lowell Waste
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: .
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
�— (example: left front of house)
VOW C
DATE OF PUMPING: C0,)'00-- QUANTITY PUMPED 1 GALLONS
CESSPOOL: NO YES S PTIC 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: 4 6v,
COMMENTS:
CONTENTS TRANSFERRED TO:
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
F-",A (example: left front of house)
'Br r-1, kli— bac-� OP �Acv;f
DATE OF PUMPING: `f 7 QUANTITY PUMPED I 5e) GALLONS
CESSPOOL: NO rJ YES SEPTIC TANK:N NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEA ACHFIELD RUNBACK.
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: l J
i
i
�'011111 nwe Ith ormassachusetts
� _ �Massachuset(s
_5ystem Puippl"M r
System Owner System Locadoll
Date of 1'umpuig: Qiiaiitity humped: Xl'�-2� gallons
Cesspool: No n '� Yes Septic 'Tank: No L_1 Yes
System Pumped by: veleedea Sfeeeolija License #
Contents translerrred to : Greater E�awrenc�sarrttary Uiatrlct
Date: _—�-- 111spector
i
Con i of Massachuse(ts
F
't
Ma sacatttsetts 1
r
6ystem Pui I _Record
System (Oder System Location
�.=� -�- .
Date of t'umpilig: Quantity Pumped: L Rllons
Cesspool: No Yes 5el)tic Tank: No Yes
_ E_
System Pumped by: varejore Sfoanhlije4 License#
Contents transterrred to : Greater Lawrence Sanitary District
Date: _ --- a Inspector.
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