HomeMy WebLinkAboutSeptic Pumping Slip - 178 BRIDGES LANE 12/28/2015 I
Commonwealth of Massachusetts
City/Town f
JAN 14 2015
y' to 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 j
local Board of Health to determine the form they use.The System Pumping Record must be submitted to t
the local Board of Health or other approving authority.
A. Facility Information
Right side of building, Left/Right front of building, Left/Right rear of building,right 'dr �f_b use Left/
1. System Location: Left/Right front of house, Left/Right rear of house, el t
g g g ' g, Under deck
Address
cay/Town /- State Zip Code
2. System Owner:
Name*
Address(if different from location)
citylrown State , Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da#e 2- Quantity P roped: Gallons
3. Type of system: ❑ Cesspool(s) [3 eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes W o If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System--'--"-
F f
6: System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca onwvhere contents were disposed:
ISIgn AHaule L owell Waste Water
Date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
_ City/Town of
System Pumping r
Form 4
DEP has provided this form for us&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 j
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 /righ side_of hous .eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner: _.
Name'
Address(if different front location)
P
City/Town G JA � e f r, I State
, �—;.o ,•r -) p Fode
�' ,)v4 Telephone Number
i' rd ;
B. Pumping Record
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 [ o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of stem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locat' h re contents-were disposed:
�.L S. Lowell Waste Water
Sign t e I Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
I
Commonwealth of Massachusetts EKK EB_
City/Town of
System Pumping Record
f
Form 4 [HEALTH WN Or NORTH AND�C p,R r
y D fkAr T t NT I
DEP has provided this form for use by local Boards of Health. Other forms may be used, bu e
information must be substantially the same as that provided here. Before using.this form, check with your t
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(_Ce /rightde of h;use2 Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under dec
Address
Cityrrown state Zip Code
2. System Owner: f_
Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
X21 I,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system- ❑ Cesspool(s) FT'Septic
Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑'No If yes, was it cleaned? ❑ Yes ❑ No
System: ��y { ` v. '
5. Condition of ...ta �r.� Fuv� I� U Imo.. �
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company ,
7. Location Mere contents were disposed:
Lowell Waste Water
GC� -----
signitufe HaulerU Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. forms may be used, ut the
t
information must be substantially the same as that provided h e., edW, 'heck with your
local Board of Health to determine the form they use. The Sys.9M#Ms be submitted to
the local Board of Health or other approving authority.
A. Facility Information
V <jdj�j� Left/
1. System Location: Left/Right front of house, Left Right rear of housi right i
Right side of building, Left/Right front of building, Left/Right rear o��i ding, Under deck
Address
-City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
-Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-9-e--pt—ic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? F-1 Yes R If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst
r4 Co _
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationwbere contents were disposed:
-L,S. Lowell Waste Water
L
-a'-A
G.
tue Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
RECEIVED
Commonwealth of Massachusetts
City/Town of
System Pumping Record
DEP has provided this form for use by local Boards of Health, Othe[r s mayy Meuse , 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 front of house, right front of hous �,Ieft side of h��s right side of house, Left
rear of house, right rear of house, left side of building, rig6t--re—br—ofbuildinq, under deck.
CityfTown State Zip Code
2 �vvner i
� ^'~~^'
Name �
Address(if different from location)
City/T wn State/ �
Telephone Number
B. Pumping Record 0 (0
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) ff-'S'e'ptic Tank El Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? El Yes If F] Yea Fl No
5. Condition of S
S, System Pumped By:
Neil J. Batamon 175821
Nome Vehicle License Number
Bateson Enterprises Inc.__
Company
7. i contents disposed:
t5form4.doc-06/03 System Pumping Record-Page I of 1
�...
Coi-nmonwealth of Massachusetts
City/Town of
i
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
Important:
When filling out 1. System Location: Left front, left rear, left side of house. Right front, right rear, right side of house.
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:
r�
Name
?+ Address(if different from location)
City/Town State Zip Code
W..-
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: [] Cesspool(s) Beptic Tank Tight Tank
that describe):
4. Effluent Tee Filter present? 0 Yes p No If yes, was it cleaned? p 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:
,
"ureof Lowell Waste Water
ir Date
t5f orm4.doc-06/03 System Pumping Record•Page 1 of 1
i
I
J
Commonwealth of Massachusetts
City/Town of
1
System Pumping Record
Form 4
5<
p p f-1
DEP has provided this form for use b local Boards of Health. Other form �����
information must be substantially the same as that provided here. Before °w rls�6rr-,"clheCk i 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
Important:
When filling out 1. System Location: Left front, left rear, eft sid of f house Right front, right rear, right side of house.
forms on the t L,
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)
it own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ] Cesspool(s) Q Septic Tank [ Tight Tank
F] Other(describe):
4. Effluent Tee Filter present? [j Yes No If yes,was it cleaned? ] Yes No
5. Condition of System:
c f toes ( I
& System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
A.S.D Lowell Waste Water
4ofH r D ate
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of'Massachusett
City/Town of I
{
System Purging Record ��"�
Form 4
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:
When filling out 1. System Location:
forms on the - `
computer,use
only the tab moVedo not
Address
to
City/Town �I �t,�... State Zi„ ^�
use the�return y p Code
key. 2. System Owner:
c;A �(,,
Name
pn Address(i(different from location)
City/Town State Zip Cade
Telephone Number
.B. Pumping .Record
1. Date,of Purnping Pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Q eptic Tank ❑ Tight:Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ff No', If yes, was it cleaned? ❑ Yes'`❑ No
5. Condi i of Stem ,
6. Systenj Pumped B
Name ehicle license Number
Comp ny
7. Locati wer conten�ts;were di "d
d:.
ILL, r~
Sig atur of auler Date
http://www.mass.gov/deg/water approvals/t5forms htm#inspect
k5form4.doc•06103 System in. Page•Page 1 of 1
Commonwealth Of Massachusetts PoEI I E
lipCity/Town of
System a r L�c.corn I . 2 00 F® ap p 6V; C�fl�� i:1 't
Hi r
DEP has provided this form for use by local Boards of Health. Other f rms ma 1;1 C"m-
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 Loc tion:
forms on the
computer,use �(�.,,-,,,'"�_"I�-
only the tab key Address
to move your
cursor-do not Cityfrown Ste Zip Code
use the return
key. 2. System Owner:
Name
man Address(if different from ration)
State Zip Code
City/Town -) ( a(
Telephone Number
B. Pumping ec r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Er Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [TAO If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi n of Syst m:
6. System Pumped y:_',k
_..,
Name Vehicle License Number
Company
ryts w e disposed:
7. Location here cont
C, __._.
Sig tur auler Date
t5form4.doc^06/03 System Pumping Record.Page 1 of 1
�L\ Commonwealth of Massach se
City/Town of
System Pumping Record
Form 4
DEP has provided this fon-n 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
Important:
When filling out 1. System Location:
forms on the (7e 4,15a,
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
gun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 2. Quantity Pumped:
1. Date of Pumping Date Gallons
3. Type of system: ❑ Cesspool(s) EI-9-e-p'tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
0�
6. System Pumped
Name Vehicle License Number
Company
7. Location w ere contents were disposed:
7
7
Signature H er Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF 061L �_6(
SYSTEM PUMPING RECORD
DATE:_LL�__O
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
C
vM 6 0 v�
DATE OF PUMPING: QUANTITY PUMPED : 150-0 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 LEACHFIE LD RUNBACK
EXCESSIVE SOLIDS FLOODED
OTHER(EXPLAIN)
SOLIDS CARRYOVER
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D_2 Lowell Waste
i
l
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
MAL'
a
k0j,<
DATE OF PUMPING: (�.. �Mda QUANTITY PUMPED G ."+ 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: LA--
COMMENTS:
CONTENTS TRANSFERRED TO:
Commonwealth of Massachusetts
A
System ' o
System Owner System Location
f - ref
Date of Pumping: Quantity Pumped: /S —gallons
Cesspool: No Yes [] Septic Tank: No [] Yes [
System Pumped by: gavna" License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
i
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Connnonwealill of Massachusetts
a
. Massachusetts
tY�pinct Record
Systerrr CJwlreI System Location
._ alla�tfs
.m na
Quantity pumped: t3
Date of Pomt�ing: �°" ,..�- � �,,,,
C'esspoof: No "' yes Septie lank: No Yea
System Pungred by: Fdewdat "#,&,AW;de4 License
Contents transl'errred to : Greater awrertce itar Uistrlct
Date: _--- tYts�aectvr: