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Home My WebLink AboutSeptic Pumping Slip - 258 BRIDGES LANE 12/28/2015 1 Commonwealth of Massachusetts City/Town of W° S stem Pumping-Record Y Form 4 M04 r 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/ iglu rear of hour Left/right side of house, Left/ Right side of building, Left/Right front of building, MTRight rear of building, Under deck Address CitylTown State Zip Code 2. System Owner,. Name' Address(if different from location) Cityrrown ' State. Zip Code Telephone Number B. Pumping record �. 1. Date of Pumping Quantity Pumped: Date Gallons a 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: /c, kv,J 6: :System Pumped B Y P Y Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. W) ere contents-were disposed: Lowell Waste Water SignAtufe cfFlaulev Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 14 F DEP has provided this form for use=by local Boards of Health. Other form's mak,be`used4�but,,the information must be substantially the same as that provided here. Before using,:ihls;fci j;`che'dk with your local Board of Health to determine the form they use.The System Pumping Record must be subm ttkto the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/Right front of house, Left Ri ht rea f , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town state Zip Code 2. System Owner: Name Address(if different from location) Citylrown Stat 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? e- ❑�No If yes, was it cleaned? [D-Yes-0 No " 5. Condition o�f SJystem 6: System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Lo 'e here contents were disposed: al S.19 Lowell Waste Water Sign t e Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 i i Commonwealth of Massachusetts u City/Town of 20 2012 u° System Pumping Record h 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 uhf„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 f r`d e �" � .o Q .� City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cityrrown State cZip Code �,C - " 7 Telephone Number B. Pumping Record 1. Date of Pumping 16 ( ° 2. uantity 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 F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: C. Lowell Waste Water G' I 41 j rte- SignAtufe I Haule Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 Commonwe,, h of Massachusetts RE 6917 RLi City/Town of System Pumping Record Form 4 TOWN OF NOR11-1 ANDOVER EHE-T."IF'H DEPARTMENT 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 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 house, Right side of house, Left front of house, Right front of house, Left rear of h Right rear of§66*�Left rear of building, Rig!�hrear of building. Address City/Town —State Zip Code 2. System Owner: 0 Name Address(if different from location) Telephone Number B. Pumping Record / //.'/ ~_~ [/ ) � � 1. Date ofPumping � � m��' � uo� ' Quantity-Pumped:- � Gallonv � 3. Type ofsystem: Tank F7 Tight Tank El Other(describe): 4. Effluent Tee Filter present? ZYes [��TVb |f yes, was itcleaned? [l No 5. Condition of � — System Pumped By: Neil Boteo n F5821 Name Vehicle License Number Bmtesmn Enterprises Inc Company 7. L7.LSAD owe aste Water ur t5mxn4doo~06m3 System Pumping Record^Page 1nf1 Commonweai,o of Massachusetts City/Town of System Pumping Record JUL, 2 8 2009 Form 4 DEP has provided this form for use by local Boards of Health. Other forms ay be,"U 51 �f V, eR ,, T N information must be substantially the same as that provided here. Before using i9Tb—rM"'Ch9Ck- it ur 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,LQca�oQ: Left side of house, Right side of house, Left front of house, Right front of house, a Yft-r6—ar Nfhous�e,.:�tight rear of house. Address (�W City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town Stan tZig-code Telephone Number B. Pumping Record 1. Date of Pumping Date Quantity Pumped: Gallons 3. Type of system: F-1 Cesspool(s) ,eptic Tank F-1 Tight Tank F-1 Other(describe): 4. Effluent Tee Filter present? 2--resEl No If yes, was it cleaned? [2:-YesD No 5. Condition of System: ( - 0 6. System Pumped By: Neil Bateson Name Vehicle License Number F5821 Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water S njiur4:'bf Haul Yale t5form4.doc-06/03 System Pumping Record•Page 1 of 1 , I TOWN OF C-7 SYSTEM PUMPING RECORD OH" ICI � I j DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) e. AA DATE OF PUMPING: QUANTITY P ED : GALLONS ONS �r CESSPOOL.: NO YES SEPTIC TANK: NO YE s NATURE OF SERVICE: ROUTINE, EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLAN ROOTS LEACHFIE LD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVE R OTBER(EXPLAIN) i SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CON'T'ENTS TRANSITIMED TO: .L. Lowell Waste i 1 f TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: I SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) Vim DATE OF PUMPING: Z I L;41 "%" QUANTITY PUMPED_' (r") 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) ISYST'E+M PUMPED BY: 122 ,4, r I; �I COMMENTS: CONTENTS TRANSFERRED TO: I 04/06/1997 15:02 5083736611 — — STEWART/ANDOVER PAGE 01 ��b ®aat fit, 's . 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