HomeMy WebLinkAboutSeptic Pumping Slip - 190 BRIDGES LANE 12/28/2015 Commonwealth of Massachusetts „ MKK V
City/Town of
System Pumping Record ;
Form 4 . WN���1F M
for use b local Boards of Health. Other for '-Uj °° "°
re�
:� ����n. H D i
DEP has provided this form o y °°s may�id"��sft, bu
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,( e ft)/Righ ar of hous`, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/bight rear of building, Under deck
9
Address t, .�
Nr iy�
City/Town — State Zip Code
2. System Owner:
. �f
Name
Address(if different from location)
Citylrown ' State Z a Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 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. Conditio o System:
6. System Pumped y:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lora' here contents were disposed:
G.L S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
Commonwealth of Massachusetts
w
City/Town of
System Pumping Record �'�' `
Form 4
i
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
i
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
Left/ I side of hous
e;L_eft
1. System Left
Right side of building, Right front of bul d g, Left/Right rear of building, U eer eck /
Address _
Cityrrown State Zip Code
2. System Owner:
rq
Name
Address(if different from location)
city/Town State Zip Code
Telephone Number
B. Pumping Record
1� 1 °` 2. trantity Pumped: Gallons
1. Date of Pumping Date
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? El Yes V 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. Loc tion where contents,were disposed:
G L S. Lowell Waste Water
Sign to a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
RECEIVED
�d��fi �„r�
Commonwealth of Massachusetts
City/Town of � rt l l()l ���°���i�i i�r;�ih�OV F,
���.A
a
0
System 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 e /Righ rear o ouse eft/right side of house, Left/
Right side of building, Left/ Right front of bui ing, Left/Right rear of building, Under deck
Address '";�Cal
Cityrrown
` State Zip Code
2. System Owner:
4w �'
Name
Address(if different from location)
City/Town °" ipa. ode
State IS--
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank El Tight Tank
❑ Other(describe):
Effluent Tee Filter resent? ❑ Yes No If yes,was it cleaned? Yes ❑ No
4. p
5. Condition of System: Du
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location,where contents were disposed:
G.L S. ,, Lowell Waste Water
Si to a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of M assachusetts
City/Town of
Record
System Pumping Afli 2 7' 0 10
Form 4 r I
T ow
OWr 000 NJPTH
w 0 1
Kq0j
Health. the Kfflf I 0� ut the
DEP has provided this form for use by local Boards of
information must be substantially the same as that provided he=re. 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. Sysjem-Location;'.Left side of house, Right side of house, Left front of house, Right front of house,
CLeft gus
.rear othose, ight re f h use Left rear of building. Right rear of building.
,�lri 0
q. c
-Address
cityrrown State Zip Code
2. System Owner:
-Name
Address(if different from location)
State Zip Code
City/Town
q-1
Telephone Number
B. Pumping Record
2. Quantity Pumped: Gallons
I. Date of Pumping Date
3. Type of system, ❑ Cesspool(s) M/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? E[I Yes Fq No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
-4a-me Vehicle License Number
Bateson Enterprises Inc
-Company
7. Location-where contents were disposed:
I.— - 1\
1 D4 Lowell Waste Water
'J -- t 1.
jgtu e of Haul �-Daite��
System Pumping Record•Page I of 1
t5form4.doc•06/03
i
i
w .
TOWN OF
SYSTEM PUMPING RECO
,r r
1, 6 2005
DATE:
TOVAH
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
� V
GALLONS
DATE OF PUMPING: QUANTITY P ED :
CESSPOOL: NO YES SEPTIC T NO
YES
NA OF
SERVICE: ROUTINE EMERGENCY
OBSERVATIONS: FULL TO COVER
GOOD CONDITION BAFFLES IN PLACE
HEAVY GREASE
LE ACIIFiELD RUNBACK
ROOTS
FLOODED
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
coNTEiNTS Sr>J
ID TO: G.L.S.D Lowell Waste
TOWN OF
SYSTEM PUMPING RECORD
DATE:_.
SYSTEM LOCATION
—SYSTEM SYSTEM OWNER& ADDRESS xample I
(example: left front of house)
A
DATE OF PUMPING: QUANTITY PUMPED : GALLONS
CESSPOOL: NO
YES SEPTIC TANK: NO YES
—
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS: FULL TO COVER
GOOD CONDITION BAFFLES IN PLACE
HEAVY GREASE LEACIMELD RUNBACK
ROOTS FLOODED
EXCESSIVE SOLIDS OTHER(E XPLAIN)
SOLIDS CARRYOVE R
sysum PumPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTE,NTS TRANSFERRED TO:
I
SYSTEM TOWN OF NORTH ANDOVER
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
00 .., j .
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)
6o
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: