HomeMy WebLinkAboutSeptic Pumping Slip - 209 BRIDGES LANE 12/28/2015 Commonwealth of Massachusetts
RECOV"-ED
city/Town of
S T
S ' tem Pumping Record
MA
Y
Form 4 '11'00,4 OF NUH 1i H ANDOVER
�IE&111 D&PARTMENT'
DEP has provided this form'for usetby local Boards of HdaltKr her iiii�sed, 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/ ntjp4L2fh2*, Left/right side of house, Left/
Right side of building, Left Right front of building,,peiqft-/Right rear of building, Under deck
Address
2-09 1\"
City[Town state Zip Code
2. System Owner:
Name'
Address(if different from location)
cityrrown State Zip Code
Telephone Number
B. Pumping Record JJ
Date of Pumping S L -Gallons 1 Date 2. Quantity Pumped:
3. Type of system*. ❑ Cesspool(s) dSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee 'Filter present? ["'Yes ❑ No If yes, was it cleaned? w/yes F-1 No,
5. Condition of System:
6. System Pumped By:
Neil Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S. Lowell Waste Water
Sign At e qtHauleV Date
t5form4.doc•06/03 system Pumping Record•Page 1 of 1
Commonwealth of Massachusetts R -CE1 V E� w� ��ow
u City/Town of
System Pumping Record �` �� �
r��wt,i o uw�g: j�wj� jwu
Form 4 u 1 a TP: i t PjF-,P
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/ oht rear of houss3 Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Addres
Citylrown State Zip Code..
-
2. System Owner:
Name
Address(if different from location)
i
Citylrown Stat n rr--� — f 'p.Code
Telephone Number
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 ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition,o S
stem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' where contents were disposed:
G AHaule Lowell Waste Water
tc w C7 Sign t Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECE,IV ED
City/Town of
System Pimping Reem d OF f4OR H ANDLY
Facility Information:
System Location:
1 6 .c
!address :
City,Towrl State Zip Code
System Owner:
Name:
.dress (if different from location of pump)
r
CAA To wn State Zap ode
Telephone Number
Pumping Record
Date of Furnping_ p ^Qua atity Pumped
Type of System. X Septic 'rank Grease Trap Other (-ghat)
System Pumped ley:
Company: ROOTER-MAN 46 Portland Street Lawrence, MA 01843
t5 Wer�.. wm
Location where contents disposed:
Signature of Hauler ��� Date
t,
I
Commonwealth of Massachusetts .w
�u
t
City/Town of `\J(
System. Pumping Record ` " a6w�°
lb i 6 PA ,.. ... ..
Facility Information:
System Location:
�7
Address
i
City/Town w. State Zip Code
System Owner:
I
Name:
Adress (if different from location of pump)
City/Town State Zip Code
Telephone Number
Pumping Record
Date of Pumping 1 Quantity Pumped_ ,. gallons
Type of System 1, . Septic Tank Grease Trap Other (what)
,M
System Pumped by: _ �
Company: ROOTER-MAN 12 East Dracut Rd., Methuen, MA 01844
Location where contents
were dispased;�'
Signature of Hauler— Date `�
9/200G, J 6: .1
.9786qQe-,l 76
HEALTH
P 6E
001-nmanwealth of m.
as ach att
City/Town of
Ord
FOCro 4
QBp has provided this form for utia b
b&-tiubmirte Y 100al Boards f Hc-a Ith, The�SXjtem Bumping d to tkl;� local 130ard of Haalth Or other-zip RacQro mw;j�
—----------- proving �mffiority.
A. Faculty info rm
)rta : ation
m
ri filling Out 'I
3 Qn Mr,
lutar�ut:e
he r�jh Wy
Ive youl
w ri�Lom OWTo'tj
2
-5tanj
Jo-
,;l,LpnQn*N�4rp 4r
PUMP'
Ing Record —------
Data of pumping A,
3. G. Quaritily Pumped:
Typo oj'sy,-,tem;
El Other Z/SePtic Tank 0 Tight Tank
4- Eftl(lonl:'Tee
YES C_] No
CanditjQn of sy$(Qm-, Y"$� W" it Qle'"d? yes No
UMPQd sy:
p-
12 EAST DRACUT ROAD
7, METHUEN,MA 01844
Will:* OQntent_9 wore
disP0,90d:
Of
jj
08/03
y Ysfm Pumpi,16 RFC0W -
t_i9 19/'U06 IS:i2 97068',ai8476
HEAL-I'l-i PAGE 02/02
RECEIVED
Commonwealth of Massachusetts
9 N (P CityiTown of NORTH ANDOVER MASSACHU TT V 17 2006
1 11
System Pumping Record 1.0
WN OF NORTH ANDOVER
HEALTH DEPARTMENT
Form 4
DEF 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,
X Facility Information
Important:
When filling out 1 Systurn Location: -------
forma on the
Computer,unc 6e s' o c
only the tab key
to move your
do 110t
Lj'*the return $tAte Zip code key,
414-� 1. 'oystem ownn.
State
2 q
Numw
E3. Pumping Record
Date of Pumping j0wb(e
No 2. Quantity Pumped:
Type of system: ❑ cesvool(s) Q21/Septic Tank Tight TaliK
D Other(describe),-
4. EffluentTee F11jol-present? ❑ Yes ❑ No if yes, wes it cleaned? ❑ Yes ❑ No
5, Condition of System,
6, System Pulnpod 6
icle '
YYU n L< ar
7. Location where contents were disposed:
Ign I r f
SyStern PurnPi,lq Record Page 1 of 1
i
i
t
Commonwealth of Massachus tts
> City/Town of f
- Gk�`�.; 0 ("1
System P'urri ing
J
Form 4
Y s
DEP has provided this form for use by local Boards of Health. Other forms maybe used, but the
information must be substantially
mine the form they user The System pumping form, check with
be your
local Board of Health to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location-,A
forms on the ., ... P
computer,use
only the tab key Address
to move your State Zip Code
cursor-do not City/Town
use the return
key. 2. System Owner.
[o
Name
�' .:�,� Address(rf different from location)
_ Code
City/Town State ! Y ip --.
Telephone Number
B. pumping Record
2. Quantity Pumped: Gallons
1. Date of Pumping Date
Cess Septic Tank El Tight Tank
3. Type of system: F1 ool s p ( ) ❑
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syste�Pumped By:
Vehicle License Number
Name •'" /,
Company
7. Location where contents were disposed:
4
lL -
Signature of Hauler Date
System Pumping Record^Page 1 of 1
t5form4.doa 06/03
i
• I
� I
TOWN OF NORTH
SYSTEM PUMPING RECORD
DATE: ) t
I
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: � 1 QUANTITY PUMPED I jCV, GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
i
NATURE
OF SERVICE: ROUTINE b/ EMERGENCY
OBSERVATIONS:
GOOD CONDITION /'FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
r�
SYSTEM PUMPED BY: � txt c err ±
COMMENTS:
CONTENTS TRANSFERRED TO:
I
@° II
TOWN OFANDOVER
I
SEPTIC SYSTEM SERVICING
REPORT
,
Date:
Homeowner: a
Pumper
Address:
a
Street
(� \�
Phone
Phone —
Nature of S-arvice: Routine
Emergency
Observations: Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive solids
Heavy Grease
Roots _-
Other (Explain)
Descript:_on of Work..
Comments:
A
TOWN OF ANDOVER
I
SEPTIC SYSTEM SERVICING
REPORT
D at e: ------
_4
Pumper ' I)Y6, �
Homeowner:_ `�� �
f / _..
„ ) jy Address: G,FlZ, C
Street
� � ;}` Phone
Phone
Nature of Service: Routine
Emergency
Observations: Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Description of Work::
Comments:
