HomeMy WebLinkAboutSeptic Pumping Slip - 42 BANNAN DRIVE 12/18/2015 i
Commonwealth ^
City/Town of
System Pumping Record NOVI � ?(M
M
a
Form 4
CEP has provided this form for use-.b local Boards of Health. Other forms �--..rb H ,
raov �
P 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
1. System Locatio a Righ rout of house eft/Right rear of house, Left/right side of house, Left/
Right side of buil ing, Left/Right fron o building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town ' Mate Zip code
elephone Number �.
B. Pumping c r
IL i
1. Date of Pumping 2. Quantity Pumped: � � .��•
Date Gallons -�
3. Type of system: Cesspool(s) Septic Tank F-1 Tight Tank
El Other(describe):
4. Effluent Tee Filter presents Yep o If yes, was it cleaned? Yes No
" 5. Condition of System:,
6. System Pumped By:
Neil Batesw F6821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio re contents were disposed:
L S. Lowell Waste Water
SignAtufa,I Haule Date
t5form4.doce 06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
_ City/Town of
System Pumping Record
a
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 Le' )/Rig runt of hall , Left/Right 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
ORA-
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown ' State Zi Code
0-1. 1--� c r
Telephone Number
i�
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑' eank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes . No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi n f S stem:
6. System Pumped By:
Neil Bateson F5821
J �
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo o • here contents were disposed:
G L S. Lowell Waste Water
Signitufe Haule Date
t5form4.doo-06103 System Pumping Record•Page 1 of 1
l
- j
Commonwealth of Massachusetts �
City/Town of
f
a
w° System Pumping Record
�.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 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 Locationt'_Le 'TRight t of house;Left/Right 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
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
L,;(S- (y0t
Telephone Number
B. Pumping Record
1. Date of Pumping ' 2. Quantity Pumped: 10 C
Date 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:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number C
Bateson Enterprises Inc "
Company
7. Location where contents were disposed:
Lowell Waste Water
qV a)).
I -
SignAtufe qt Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECOVEP
City/Town of
NO 10 2009
a y stem Pumping Record V
Form b 3 TOWN 01:NORTH ANDOVER
HEAD ti DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may U6used, but the
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 hour , Lft front of'�hou , fight front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address
Cityrrown State Zip Code
2. System Owner:
S
Name
Address(if different from location)
City/Town �State Z Zip Code
0- 0
Telephone Number (6
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
1 Type of system: ❑ Cesspool(s) B—Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
& System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location whe[e contents were disposed:
G.LS.7a Lowell Waste Water
Signature of Hauler Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of I � air V�,""I
System Pumping Record
Form 4 GCE C; 1 5 ?006
w� i
DEP has provided this form for use by local Boards:of Health. T : um id e"crd must
. g.
be submitted to the.local Board of Health or other approving aut t�.. �� Gm °pi° °°�' i
A. Facility Information
Important:
When filling out 1. System Locatio ,
forms on the
computer,use 44
only the tab key Address
to move your
cursor-do not -
use the;return Cityfrown Sta e Zip Code
key.
2, System Owner:
Name
Address(i(different from location) .
Cityfrown State
Zip��,oiie`
C
Telephone Number
.B. Pumping Record
1, .Date.of Pumping pate 2. Quantity'Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tigbt;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-"
. Pw
yy
:Name Vehicle license Number
..
Compa6y~ -
7. Locati' w here contents we re osed::
,
Signal e o au Date -
http://www.mass.gov/dep/w er/a proval8/t5forms.htm inspect
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
i
TO OF
FEB
DATE: r
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front ont of mouse)
� mw
Or I
F
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 LEACIMELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTBER(EXPLAIN)
SYSTEM PUMIE D BY: Bateson Enterprises, Inc.
COMMENTS:
�uw
CONTENTS TRANSFERRED TO: .L. .O Lowell Waste
I
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: -y C
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
c.
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:
i