HomeMy WebLinkAboutSeptic Pumping Slip - 261 BRIDGES LANE 12/28/2015 Commonwealth of Massachusetts
City/Town of
n r N✓4 46 Y
System Pumping Record
Form 4 _
1
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 hoes. a rig h Ile:of hog:so eft i
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: _-V(,eA
Name
Address(if different from location)
cityfrown State � -4pp Code
Telephone Number
1
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
Sep tic Tank ❑ Tight Tank
3. Type of system: ❑ C spools) 5
ther(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No.
5.
Condifin of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' where contents were disposed:
C'.x.L S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
�
Commonwealth of Massachusetts RECEIVED
RECEIVED
CityfTown of
System Pumping Record
TOWN OF NORTH ANDOVE
HEALTH DEPARTMENT
E' ' ",_
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 OF other approving authority.
A. Facility information
front Left' System mea of house, Right neor of house. Left rear ufbuilding. Right rear mVbuilding. .
ress
L_� ��
'^-- �� /�` f ��� (�� {�, l/\ V~~_/dll�``
Cityrrown State Zip Code
2. System Owner:
Nome
Address(if different from location)
,~ 0 .� Code
City/Town City/Town ��__(~�����
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: -da-llons -
Date
3. Type of system: Cesspool(s) Q-S-e-ptic Tank F] Tight Tank
Fl Other(describe):
4. Effluent Tee Filter present? El Yes |f yes, was itcleaned? El Yes No
5 C}ondidonof�ystenn \
�
, _-
6. System Pumped By:
NeU8eteson F5821
-ka-me Vehicle License Number
Bateson Enterprises Inc
:ompany
7. contents disposed:
G.L.S. Low 11 ste Wate�r
t5form4.doc-06/03 System Pumping Record^Page 1of1
Commonwealth of Massachusetts
ity/T® n of
RECEIVED
System pumping Record
Form 4 NOV J 4 2007
k1pi r use by local Bo rds of Healt . th f 'nay be used, but the
I
DEP has provided this form for A ing this form,check with your
3 AWNWM
same a t T
information must be substantially the same as wwo Record must be submitted to
I
local Board of Health to determine the form the
local Board of Health or other approving authority.
Facility Information
Important; _ ;
When filling out 1. Systel Locati n-
forms on the
computer,use
Address
only the tab key
to move your —State I Zip Code
cursor-do not c4frown
use the return
key. 2. System Owner:
VQ Name
ream Address(if different from location) stag Zip Code
cityrrown —o(?
-telephone Number
B. Pumping Record
1. Date of Pumping Date l 2, Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) []-!�,eptic Tank ❑ Tight Tank
❑ Other(describe): n Yes EPKO" if yes,was it cleaned? ❑ Yes ❑ No
4. Effluent Tee Filter present?
15 Condition of System:
6. System fu By:
Name Vehicle License Number
-Company
7. Location re c ritents ere sed-
7
Date
Signatu ler
System Pumping Record m Page I of I
t5fon-n4.doc-06/03
l
Farm 9 -- system Pumping Record
I
Commonwealth of; ssachusatss. 1
Massachusetts
n
systems
system Location �
v
1 b il,yi r
ii W
Type. Routine
yes septic tank: i`!o Yes
cesspool: Quantity Pumped:Quantity aumpad: ,J
spate of Pumping;
system Pumped Sy;
Wind River EnvironWnW, UC° a it :
Contents transferred to'
Contents Disposed at
bate, Pumper Si turn:
Condition of 5yste WOth w Comments
w,-- A....woe] Fern, - 12/07/95
Farm 4_- System Pumping Record
commnweolth of Mossachusetss
Massachusetts
(stem Pumping R I,
iI
f
System Owner System Location
11 A r r'i y1 >, s I rA
Type: Emergency Routine
Cesspool. w Yes Septic tank: w Yes
Date of Pumping: , , . Quantity Pumped; Gallons-
System Pumped By: Wind River Environmental, UC Permit
Contents transferred to
Contents Disposed at
Date: Pumper Signature,
Condition of system/Other Comments
i
i
a
i
lep Approved From - 12107195
I
I
1
FOT'M 1-SYSTEM PUMPII�G'REC()RD
CURRIER
�4
I u7 FOREST�STRUM; MLDDt EsTCS:V :NIA 019-x9
CC'Wvf0NWBALTH OF MASSACHUSETTS-
d0r - l�IASA C]EtJS;�TTS
SV'S TEIV PUMPING RECORD
Sys-re.Nri OWNlI�R. SYSTEM LOCATION:
� 1
r
� I
DATE OF PI-TIMPNG: 1 ( -3 C,;)I.ANTITTi'PUldUD: /5 6 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES µ
SYSTEM.PU-N/LPED BY: CURRIER SEPTIC & DR,,klN SERVICT
CONTENTS T".NSFERRED T0:
DATE:
�r
TOWN OFj�ANDOVER
SEPTIC SYSTEM SE-RVICING
REPORT
Date:__ �m (_`� �
Homeowner: �–�--�--__
Street _ ' >, J� Pumper o
Phone y
;, Address
Phone
--` L
Nature of S.Drvice:
Routine
Emergency –
Observations
Good Condition w ,-......_
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Descriptior, of Work:
- - -- __ _ter —►
comments :
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