HomeMy WebLinkAboutSeptic Pumping Slip - 173 BRIDGES LANE 12/28/2015 Commonwealth of Massachusetts
,
City/Town of .
S item Pumping,Record - 232015
Y 9
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 1
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left XQ ht front 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
147
_
Cityrrown State Zip Code
2. System Owner:
et ram
Name
Address(if different from location)
Citylrown - State Zip Code
w L. 17
-,,
Telephone Number
B. Pumping Record _ m
1. Date of Pumping bate 2. Quantity Pumped:
Gallons -
3. Type of system; ❑ Cesspool(s) O-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0-ho 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. Lopation;Aqh a contents were disposed:
Lowell Waste Water
SignAtufe qf HauleV Date
t5form4.doe•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
= City/Town of
System Pumping a ord
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/r54ht front of hour, 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 differ fnt from'I ocation)
City/Town o ro y h �,q 14 1 State 5� Zip Code ;
"n(
Telephone Number 1
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 f, ystem:
0 o.r ki\j'`-61
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Locat n- contents were disposed:
a, S, Lowell Waste Water
Sign tule,I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
. E(;EIVED
Commonwealth of Massachusetts
City/Town of Nov °
a System Pumping Record
� awa��aa
Form 4 t as A,1'1 a a)E PA �v a:
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 side of house, Right side of house, Left front of house fight ront of hous ,b
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address
Lv' ,Ai aver
City/Town State Zip Code
2. System Owner:
Name
I
Address(if different from location)
City/Town State t Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping I _ ( 2. uantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M 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 where contents were disposed:
D ' j Lowell Waste Water
Ygrptute of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of ECEIVED
c System Pumspin g Record
Form 4 DEC -8 MI
GM f
TOWN OF NORT�� 10)
DEP has provided this form for use by local Boards of Health. Other fo m P"A
information must be substantially the same as that provided here. Before DE
is=, ith 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 ig;hit front of h�use,, eft/Right rear of house, Left/right side of house, Left
0 ous
t 11c
<(i f�Ofuilding, Left/Right rear of building, Under deck
Right side of building, Left igh ront of b
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State ZIP
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 9--Septic Tank F-j Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2--N�o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
J,
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc " n w ere were disposed:
G.G S.11
.jLS. Lowell Waste Water
Sign toe Haulev Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
local Commonwealth of Massachusetts VED
City/Town of
System Pumping Record
TOWN OF Nwrll ANDOVER
[HE:ALTH DEPARI E
DEP has provided this form for use by local Boards of Health. Other orms may e used, but the>
information must be substantially the same as that provided here. Before using this form, check with your
___- _ .__-. -~___---_ -_ _.. -_` --_ ._ _,-_'.. . _,-= .___- .._-'_---_---_ _-
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 ho e, Right front of house
U'&
Left rear of house, Right rear of house. Left rear of building. Right rear of bui
Address r-? ::> i�' -
~"r'o°' State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town S
Telephone Number
�
~~
]�~ ��u��^�~n� Record
1. Date ofPumping om° 2. Quantity Pumped: Gallons
3. Type ofsystem: Cesspool(s) 0-8�ephoTmnk El Tight Tank
[l Other(describe):
4. Effluent Tee Filter present? El Yes D'No |f yes,was itcleaned? 0 Yes El No
5. Condition
6. System Pumped By:
Nei| 8mteaon F5821 �
Name Vehicle License Number �
8ahesonEnhe h Inc
Company �
7. LocaTfi�o",be�e contents were disposed:
LO
,,well Waste Vqter
ul Date
Signature oflA 7'
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
�___~_
Commonwealth.of Massachusetts
1
City/Town of I I
System Plumping Record
Form 4 J
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
. � -•---�� '( 7 •
When fillip out System Location:
farms on the
computer, use �
�-
only the tab key Address
to move your ° !
cursor-do not
use the-return Cityrrown State Zip„ e
key. 2. System Owner:
Name
dress if different r ° C IJ
Ad_
= I t- t f om location) t7t „
City/fawn Sta `
ode'
Telephone Number
B. Pumping Record
1. Date_of Pumping pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cess'pool(s) epticwTank- Tight.Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes PIC If yes, was it cleaned? ❑ Yes`❑ No
p R
5. Condition of System:
6. System Pu pe By,,
Name V4� jcle,t cep§a Number
Company
7. Location ire contents w e di ed:,
°
Signatur of ul Date
http://www,mass.gov/dep/wat '/approvals/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1
TOWN OF 14��(
fry
SYSTEM P#'MPING RECO
R
ECEIVED
DAT 8 20()
DOVER
0
M
E: ju- - 8 2'004
T :oWt� F NORTH AND V R
T T
HEAqr P TMENI
H L T P
EAOLTDE AR
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
(example: left front of house)
-t( C
DATE OF PUMPING: QUANTITY PUMPED : G-ALE
ONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF.SERVICE: ROUTINE, EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE 'BAFFLES IN PLACE
RObTS LEACHRELDRUNBACK
EXCESSIVE SOLIDS FLOODED I I
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMIE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED To: G.L.S.D Lowell Waste
I
TOWN OF NORTH ANDOVER.
SYSTEM PUMPING RECORD
DATE: _ C
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
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: rA'_'I
COMMENTS:
CONTENTS TRANSFERRED TO; '