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FORM 4 - SYSTEM PUMPLNG RECORD
Commonwealth of Massachusetts � ��"��;�„����a��
Massachusetts
S stem Pumping Record
JVStem er Tdea —Sys-tern ocati n ..m
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C o t.) � A
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17
Tvpe: Emergency ❑ Routine 2
Cesspool: No ❑ Yes ❑ Scptic Tank: No ❑ Yes
Date of Pumping:
9- �M Quantit-\l Pumped: gallons
Svstem Pumped by (Company): ” '" " M Permit ..
Contents transferred to:
Contents disposed at:
Signature
Date
Date Pumper
Condition of system/other comments:
DEP APPROVED FOW i- 1'.107/9S
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M
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Commonwealth of Massachusetts
City/Town of f e 013
{1
"r 1
System Pumping Record r
Form 4
i
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 a righ lde f house Left/
Right side of building, Left/Right front of building, Left/Right rear of bul ding, Under ec
Address
Cityrrown State Zip Code
2. System Owner: ` hll�" 1
Name
Address(if different from location)
City/Town Sta t P"s; Zip d
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quanti ty Pumped:
Gallons
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:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati a contents were disposed:
G S. Lowell Waste Water
Sign$tufe Haute Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
r
Commonwealth of Massachusetts � 021' '1 c"':
City/Town of � f,f " f
n 1¢�
System Pumping Record
w ,
Form A
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 si a of house; eft/
Right side of building, Left/ Right front of building, Left/Right rear of building, n�er ec ck-
Address
.q �'6 G� ►� . oar" - .
Ci#ylTown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pat _ ( ` 2. Quantity Pumped: Gallons t
3. Type of system: ❑ Cesspool(s) M//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. Locatiorvwh re contents were disposed:
G.L S. Lowell Waste Water
Sign toe Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
Commonwealth of Massachusetts
City/Town of
System i cor li 'w p b'�
Form 4
�,yp�ry,�p'y�p+p��,p/�y,gpy{w�q{¢ f
4 Y"6914m?M R H P�"PoY^39w?MuW Vf '.
DEP has provided this form for use by local Boards of Health. Other fo rr W#0 ftsiMl
information must be,substantially the same as that provided here. Befo arm, 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 Locati . eft side"of hour, Right side of house, Left front of house, Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address @ f 1 A
Cityrrown State Zip Code
2. System Owner:
ex
r
Name
Address(if different from location)
City/Town State 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. Condit' n of System:�
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatia here contents were disposed:
G.L;S,O Low W Water
Signatur of ule Date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
i
I
Commonwealth Of Massachusetts
City/Town of
W
System Pumping ec rd (:T 2 3 0
ya
` Form 4 F
DEP has provided this form for use b local Boards of Health. Other
y 466ms rrtay tie rased, 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: ,v
forms on the
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:
VQ ( .> n,
Name
,n Address(if different from location)
City/Town State Zip Code
`(—. l f 3
Telephone Number
B. Pumping r
JO l 6 57 �
1. Date of Pumping ®ate 2. Quantity Pumped: 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 ystem: 0 p
6. System u ped By; �
env l � � C
Name _ Vehicle License Number
Company
7. Location where contents w re dispo ed: f �
Sign ur auler Date
I
t5form4.doc^06/03 System Pumping Record•Page 1 of 1
I
7'b:WN OF NORTH 'ANDOVER
SYSTEM PUMPING R. CORD
OWNER A D D R E 8 w SYSTEM LOCATION
(Mmple; lCf( front of hou>e)
,36 z~ C o1
OF PUMNINC;
QUANTITY I'UMI'CD °, �e") CAL l.(�ti �
NO YES SEPTIC TANK; NO YES A,
ew
' -ATURE OF SERVICE; ROUTINE � EMERGENCY
11ll.>rRY.�TIONS,
GOOD COND11'10N. FULL, TO COVER
HPAYY CREASE BAFFLES IN PLACE
HOOTS LEACHFIELD RUNDACK...
CXCESSIYE SOLIDS FLOODED
SOLIDS CARRYOVER p HFR (EXPLA.IN)
EM PUM f CD BY 'Y
C (J)]kl rNTS.
tlI ANSFCIZRED TO
1
1
i
TOWN OF/
SySiE-MPUMPIN"',G , CORD
DATE: 1
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of horse)
DATE OF PUMPING: ` QUANTITY PUMPE D a GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YE S
NATURE OF SERVICE: ROUTINE EMERGENCY
GD ERVATIONS;
GOOD CONDITION FULL TO COVED
HE"Y GREASE BAFFLES IN PLACE
ROOTS LE ACIIFIE LD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTBER(EXPLAIN)
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
fl
CONTENTS T S+ + D TO: BL. . Lowell Waste