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HomeMy WebLinkAboutSeptic Pumping Slip - 185 BRIDGES LANE 12/28/2015 f Commonwealth f Massachusetts :.. City/Town oi YS Form 4 ®EP has provided this ford foe us&by local Boards of Heal h-6ither forms may be'us�ed, but the d 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 I 1. System Location: Left/Right front of house, Left/Right rear of house, Left4 jrg--t-_side of ho� , Left/ Right side of building, Left/Right front of building, Left/Right rear of building, IJ�r eck Address .--- (a City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cityfrown ' State C' ip Code 'telephone Number B. = t Pumping c r 1. Date of Pumping 2. Quantity Pumped: Date Lallans 3. Type of system; Cesspool(s) Septic Tank El Tight Tank El Other(describe): 4. Effluent Tee Filter present? El Yes El—No---- If yes, was it cleaned? El Yes ® No. ' S. Condition of System: 6. System Pumped By: Neil Bateson F5621 Name Vehicle License Number Bateson Enterprises Inc, Company 7. Locatiqt. h contents were disposed: M.. SQ ' Lowell Waste Water } Sign t Haute Cate t5form4.doc-08103 System Pumping Record.Page 1 of 1 I Commonwealth of Massachusetts = v City/Town of y• t Pumping Record 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/Right front of house, Left/Right rear of house, Left/ ic`ight side of h® a, Left/ Right side of building, Left i Right front of building, Left/Right rear of building, Under deck Address �-- `� t w City[Town State Zip Code 2. System Owner: Name' i Address(if different from location) City/Town State -,L.7,7� Zi C de Telephone Number ' f B. Pumping Record . 5 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? ❑ Yep 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- DE(' Company 7. Locaf contents were disposed: L S. Lowell Waste Water -Q4KOA. ...�-�-�-- SignAtufe Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts H City/Town of System Pumping r .`o Form 4 E 4 DEP has provided this form for use by local Boards of Health. ut the information must be substantially the same as that provided h heck 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 ode of , Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Addres B�' �:.°_ °L Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town Stat$-7 � c�- ode 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 ©--Iqo If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of Sste 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location were ontents were disposed: Lowell Waste Water Sign tu'e Haule Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 Commonwealth of Massachusett-q City/Town of System Pumping Record 14 Form 4 VWN OP NWHANOVER DEP has provided this form for use by local Boards of Heal . GffAkftft8AAb�d, but the 0 using(:r I information must be substantially the same as that provided[hhere. Be ore usingthis 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 house, left side of hous jqht side�of ho�qs Left 4�' rear of house, right rear of house, left side of building, right rear of building, c g, under e City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town 2�1��Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ cesspool(s) fft—Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition-oTM.'_,'� 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Locafiqn-where contents were disposed: L.S.D. 1-34vell Waste WatV—) Signatur of Maulbr Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 i Commonwealth of Massachusetts FR City/Town of . w System \j Pumping Record N� ANDOVER 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 side of house�g t side of houeft front of house, Right front of house, Left rear of house, Right rear f house. 'C c Address City/Town State Zip Code 2. System Owner: &I t 6U, e Name Address(if different from location) City/Town State Zip Code Telephone Number U `C B. Pumping Record 1. Date of Pumping ` g r 2. Quantity Pumped: 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 Bateson Name Vehicle License Number F5821 Bateson Enterprises Inc Company 7. Location,/wh ")contents were disposed: G.JL. . Lowell Waste Water S' n f Haul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of ��ao b System Pumping Record Form 4 ; DEP has provided this form for use by local Boards of Health. Other forms-maybe used;,bttt:lhb information must be substantially the same as that provided here. Before using,�this_fo'rm;.. ` k va th 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 ous h . forms on the computer,use only the tab key Address to move your < cursor-do not CitylTown State Zip Code use the return key. 2. System Owner: &i 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: p Cesspool(s) FrSeptic Tank [] Tight Tank Q Other(describe): 4. Effluent Tee Filter present? El Yes 0-- to If yes,was it cleaned? [j Yes No 5. Conditiop of Syste � 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Mure ere contents were disposed: Lowell Waste Water u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 i Commonwealth of Massachusetts City/Town of � System Pumping Record (0 Form 4 <d4 xRT H ANDOVE 1 1)-i ltEPAR Mr W- DEP has provided this form for use by local Boards of Health. Oth fd rx�ay ie u; utt e 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 Inr ation Important: When filling out System 1 S Location- forms l 1 C .. ..._ .., y on the only he tab key ~� to move our �' �.-� c ;,..... computer,use y y Address y __�.. m cursor-do not Cityrrown State Zip Code use the return key. 2. System Owner: Name � Address(iF different from location) Citylrown State Zip Code Telephone Number B. Pumping ecor 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 [3,-No If yes,was it cleaned? ❑ Yes ❑ No 5, Condition of System: 6. System P mped By: ic Name ehicle License Number Company 7. Location w ere co,tents were sp sed: w� Signat u Date t5form4.doc^06103 System Pumping Record o Page 1 of 1 i Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 f DEP has provided this form for use by local Boards of Health. The System Pumping Record must fie submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Qcation: forms on the ... ..._..`. � -~` computer,usem�" Y to move tab our Address .- µ .. µ Y IV cursor-do not � �--� � use there#urn City/I own State ode — 2.. System Owner: r� riS � ANDO\j k l Name Address(i(different from location) City/Town Stat�e� de Telephone Number B. Pumping Record 1. Date-of Pumping oats 2. Quantity Pump' Gallons 3. Type of system:- ❑ Cesspool(s) Septic Tank-. El Tight.Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: t, a :,J" 6. System Pumped By. Name - ... Vehicle,License Number Company 7. Locati d w'hele ante,nts efe sed:: Signatur of au r Date http://www,mass.gov/dep/ ater/a ptovals/t5forms.hthl#inspect t5fomt4.doc-06103 System`Pumping Record•Page 1 of 1 i V i T ., SYSTEM PUMPING RECORD NOV 18 200 TOWN OF NOWH ANOOVER HEALTH DEPAFUMENT DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (examples left front of house) J i ---GALLONS DATE GT PUMPING: UANTITY ED CESSPOOL: NO YES SE IC T > NO YE S NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER GREASE HEAVY FL S IN PLACE ROOTS LEACHIIIE LD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O R(E L SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: .Lo II t TOWN OF SYSTEM PUMPING RECORD Per DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) (x- b U DATE OF PUMPING: QUANTITY PUMPED : GALLONS CESSPOOL,: No t--�YES SE PTIC TANK: NO YE S NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION F UL L TO COVE R HEAVY GREASE BAFFLES IN PLACE ROOTS LEACH KIEL D RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTI-JE R(EJ XPLAIN) SYSTEM PumEL)BY: Bateson Enterpnises, Inc. COMMENTS: CONWNTS'rRMSFERRED TO: G.L.S.D- Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) k DATE OF PUMPING: Q ANTITY 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 I Commonwealth ofmassacllusetts i Masscltttsetts i 93yqtem P r System Owner System vocation Date of Pumping: - Quairtity Pumped: - gallons r s Cesspool: No ( � Yes IJ Septic Tank: No Yes System Pumped by: varejart gfeamhlide4 License # Contents transferrred to : C3teeter awrence e'�ltery District Date: _ _ ]rrspector: fi rf,r Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location po-�(v- :tr--s Date of Pumping: C r� Quantity Pumped: gallons Cesspool: No Yes ❑ Septic Tank: No ❑ Yes*D System Pumped by: lrlr`` License# Contents transferrred to ; Greater Lawrence Sanitary District Date; Inspector;