HomeMy WebLinkAboutSeptic Pumping Slip - 222 BRIDGES LANE 12/28/2015 � d
s
Commonwealth of Massachusefts
City/Town
System Pumping Record Z014
Form 4
�urJ OF KASH ANDOVER
DEP has provided this form for use-.by local Boards of Health the �� „�- d, ut the
information must be substantially the same as that provided hey":` ef6re 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. I r tI n
1. System Location: Left/ root of hours,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 y
i D `i
Cityrrown ! State Zip Code
2. System Owner: f �'
Name
Address(if different from location)
City/Town ' State ] - i e
Telephone Number
i
B. Pumping Record .
1. Date of Pumping Date 2. Quanti Pumped: Gallons
3. Type of system: Ej Cesspool(s) Septic lank El light lank
El Other(describe):
4. Effluent lee Filter present? El Yep o If yes, was it cleaned? Yes No,
5. Condition f stem:
6. System Pumped By:
Neil Bateson F5321
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. 7atL.S-P w�a contents were disposed:
� Lowell W aste Water
Agn WHa Date
t5form4.docm 06/03 System Pumping Record m Page 1 of 1
Commonwealth of Massachusetts
u
City/Town of
System Pumping Record
Form 4
I
DEP has provided this form far 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 t
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left Righ front of hogs , 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
1
Address
City(rown State ✓✓�� Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' Stat i Code
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 No If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of System:
6. System Pumped By:
Nell Bateson F5821
Name Vehicle License Number �
Bateson Enterprises IncE
Company ,
a
7. Locaf n.. here contents-were disposed:
Cl.L S Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
r
Commonwealth of Massachusetts
City/Town of
System Pumping Record ` s
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/ ight front Left/Right rear of house, Left/right side of house, Left Right side of building, Left/ Right front of bulding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner: �-
Name
Address(if different from location)
City/Town State,/� � � Code
Telephone Number
B. Pumping Record
U-
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 Systeamn-
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. jSigntu' VHaulev contents were disposed:
Lowell Waste Water
Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
w
Commonwealth of Massachusetts
,SCEIVED.
City/Town of
System umpin Record S�
.�` Form 4
� ii w ,E' ��
DEP has provided this form for use by local Boards of Heal „�.❑ orfrrs mi be used, but the J
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ 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 hou eRight side of hous Left front of house, Right front of house,
Left rear of house, Right rear of house. ding. Right rear of building.
4
Address
Citylrown State Zip Code
2. System Owner:
Name
Address(if different from location)
CitylTown State
Telep one Number
B. Pumping Record
f'T
1. Date of Pumping Date 2. Quantity Pumped: Gallon
,.
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D''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:
G.L. .D Lowell Waste Water _}
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
AJ"TO" OF
A �
SYSTEM PUMPING
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
n (example: left front of house)
fro
DATE OF PUMPING: _ QUANTITY PUMPE ID D . 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 LEAC +IELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHE R(EXPLAIN)
SYSTEM PUMPE li BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L. Lowell Waste
i
i
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTE OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
DATE OF PUMI ING: QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS: t
GOOD CONDITION FULL TO COVER
HEAVY GREASE RAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OT R(E L
sYsum PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONTENTS TRANSFERRED TO: .L. Lowell a ate
,01,111lot,wealth of Massachusetts
�)A,; assqchusetts
System Pum in -Record
System Owiter System Location
C-4 c
Date of Pumping: Quantity Pumped: gallons
Cesspool: No Yes Ll Septic Tank: No Yes
System Pumped by: varederf, 6(flaola—e-4. License
Contents transreurred to : Greater Lawrence Sanitary District
Date: Inspector