HomeMy WebLinkAboutSeptic Pumping Slip - 31 BANNAN DRIVE 12/18/2015 i
Commonwealth of Massachusetts
City/Town of .
YS tem Pumping,lRecord
Form 4
DEP has provided this form for use.by local Boards ofliealth!,Other fofffig,may be'used, but the
information must be substantially the same as that provided h6r6U'Bafa1l`e 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 21 ht rear of house Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig t rear o building, Under deck
Address
d l` d
City/Town state Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown ' state Zip Code ;
Telephone user
i
B. Pumping jRecord
1. Date of Pumping �'� _ 2. Quantity Pumped: ---1 =
Date 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:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location-where contents-were disposed:
G_I S Lowell Waste Water
pW '- �
Sign e9t Hauie Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
,�,y1 w/p�� y1ya�1, Massachusetts
1
��,,Y��®O Commonwealth I ��
City/Town of
w� System Pumping Record
w 0 4
Form
�
4 1
DEP has provided this form for use by local Boards of Health IhpJrgrms�m ibwu t the ?
information must be substantially the same as that provided her �r�eFLI 'tli forh,, eck th your
local Board of Health to determine the form they use.The System Pumping Record must itted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Loc ion:
forms on the
computer, use
only nly the the tab key Address �..
to move your �c "\V\J�" � /
cursor-do not
use the return City(rowm State Zip Code
key. 2. System Owner:
Name
ream Address(if different from location)
Cityrrown StatnC -- Zi Code
, � °
Telephone Number
B. Pumping
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.. o N If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6, System Pum ed By:
Name - Vehicle License Number
Company
7. Location ere cante�were spaced:
A.
..w
Signatur of u r Date
t5form4.doca 06/03 System Pumping Record•Page 1 of 1
Commonwealth.of Massachusetts ECEIVE
City/Town of I �
System Pumping
Record .���. � JANDVER
Form 4
LOON F NORTH PALWTH DEP
DEP has provided this form for use by local Boards of Health. The yssem Pumping Record must
be submitted to the local Board of Health or other approving authority. .
i
A. Facility Information
Important:
When filling out 1. System Location:
forms on the ��CL) "
computer,use
only the tab key Address
to move your - '
cursor-do not
use thwreturn City/Town State Zip Code
key. 2. System Owner:
:: "C�
Name
Address(if different from location)
CitylTown State
Zip 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 o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
C c lam
6. System u pe,' B
Vehicle Lice.
e nse Number
Nam
Company --
� ased:
7. Location re contents e re
Signat e o ler ate
http://www.mass.gov/de /wa er/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System'Pumping Record.Page 1 of 1
i
i
t
TOWN OF
SYSTEM PUMPING
° a "a"
DATEa . I(
�v r
� C)FRTH pND
SYS EM OWNER & ADDRESS SYSTEM LOCATION
Le✓ .., (example: left front of house)
DATE OF PUMPING: QUANTITY PUMPE D > GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
H "Y GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCE SSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHE R(EXPL
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
Co NTS SFEi D TO. Lowell Waste
i
TOWN OF vlkk(
SYSTEM PUMPING RECORD
DATE: ` ( .
SYSTEM OWNER & ADDRESS SYSTEM LOCATION `
(example: left front of house)
DATE OF P ING: `�- U U P ED : GALLONS
CESSPOOL: NO YES EPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HAY GREASE BAFFLES IN PLACE
ROOTS LEI ACIMELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OT (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONTENTS TRANSFE RRE D TO: cam'