HomeMy WebLinkAboutSeptic Pumping Slip - 56 BRIDGES LANE 1/6/2016 Commonwealth of Massachusetts
` ��E
_ City/Town of I:
JUN I
System p' Record
Form 4 � u� �s �b. �:
fit. tt r r f,Not u:
w ...r, w
DEP has provided this farm 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
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house&&IghKWE02 ouse
Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address AA.
11-j ci
Citylrown state Zip Code
2. System Owner: �
Name
Address(if different from location)
City/Town Stag 7 �y d
f
I"r
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 of
6: System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7.ISIgnt where contents were disposed:
pHaulet/ Lowell Waste Water
Da te
t 5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Ith of Massachusetts
_ City/Town of y
J kMF W Ste„.0 (A �I
b
System r
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/Right rear of house,(Ce /right tde of hho..use„eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �•. L J V A k d o V-0�
Cityrrown State
Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
(y 591 S
Telephone Number
li
B. Pumping Record
1. Date of Pumping 11 y ��” 2. antity Pumped: 1` 0 i
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
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L�G.atio ere contents were disposed:
ti
L S. Lowell Waste Water
Sign toe Haule Date I(—
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of � �"I " t�����
a System Pumping Record
14 0
Form 4 "4x r .
G1
TOM)C)F NOR`raj NraCm:S�
DEP has provided this form for use by local Boards of eafthi�Olthex*g4*p`aV b used, but the
information must be substantially the same as that provided 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 housqoa right�s"`id of house?Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address `�
City/Town ICJ State Zip Code
2. System Owner:
Name
Address(if different from location)
i
City/Town State
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 [ If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f Sy tem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc iotrwh re contents were disposed:
G#L,SPHaule Lowell Waste Water
Sig Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
RECEIVED
W City/Town of
a
System u 'n Record "d°,r"'�
Form 4
TOWN OF NORTH ANDOV
G'Af S
DEP has provided this form for use by local Boards of Health. Other
information must be substantially the same as that provided here. Before using this form, c 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 front of house, right front of house,,I side of house right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
6-& B -\ ❑,, A,�, (A❑ 4-0,-Af
City/Town State Zip Code
2. System Owner: I(��,,C-���`�� ❑��,
U �
Name
Address(if different from location)
City/Town State Code
'-��-- �,
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date +rte... Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 � If yes, was it cleaned? ❑ Yes ❑ No
5. Condit'6n of System: q
V\- 4z--,t�
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locatio wh I
.L.
e contents were disposed:
GS.D. o II Waste ater
Signature f ul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
�
Commonwealth
��^����lK���\8y����,n " ^�/ `.
City/Town of �u
System Pumping Record
DEP has provided this form for use by local Boards of Heal but the
information must be substantially Ul that novd 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: , ightside of house, Left hnntof house, Right hnntofhouse,
Left rear of house. use. Left rear ofbuilding. Right rear ofbuilding.
Address
City/Town State Zip Code
2. System Ow
Name
Address(if different from location)
CinfTown State
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type orsystem: LJ Cesspool(s) 9g-epoc /anx El Tight Tank
[l Other(describe): �
�
�
4. Effluent Tee Filter F] Yes 9-1q0 K yes, was itcleaned? Fl Yes El No �
5 Condition �
� _'-_� �
6 System Pumped Bv �
�
NeUBabaaon F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatip h re contents were disposed:
L.S.D _Y Lowell Waste Water
Signature of Hauler Date
mmrm4doo^06/03 System Pumping Record^Page 1oy1
Commonwealth of Massachusetts
City/Town of I
System Pumping Record
Form 4
DEP 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. .
A. Facility Information
Important:
When
forms on the
computer,use Location:
filling out yste
�
to
only the tab
cursor edo your not
y Address .E
use the return City/Town — Vtte Zip Code
key. 2. System Owner:
,m
Name
Address(i(different from location)
Cityrrown State `o ,
Telephone Number
B. Pumping Record
Pate ntity`Pumped: Gallons
1. .Date.of Pumping 2 Qua
3. Type of system: ❑ Cesspool(s) Q Septic Tank-_ °... gfit:Tank
❑ Other(describe)`
4. Effluent Tee Filter present? ❑ Yes ®°Ivor If yes, was it cleaned? ❑ Yes ❑ No
- 5. Condition of System:
6. System Qum eddy-..
:Name yehicl eicen§e Number
Company
7. Location where yc�ontents were ' . osed::
Signature Ha r Date
http://www.mass.gov/dep/water/ pp�vale/t.9forms.htm#in'spect
t5form4.doc•06103 System Pumping Record-Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD
DATE:
'p
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
® (example:left front of house)
By"
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)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.&D Lowell Waste
TOWN OF [� 8 Avjwec
SYSTEM PUMPING RECORD
DATE: �--
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: �L) t�l ' d o`L QUANTITY PUMPED : 1 Ste_ 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)
SYSTEM PUMPED BY: Bates®n Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: "�
TOWN OF NORTH ANDOVER
SYSTEM PUMPING CORD
DATE: _o
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
C GEC I i
(example: left front of house)
'C
DATE OF PUMPING: 0 QUANTITY PUMPED GALLONS
CESSPOOL: NO . i, 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)
SYSTEM PUMPED BY: �
2 GJ-
COMMENTS:
CONTENTS TRANSFERRED TO
Commonwealth ormassachusetts
Massachusetts
g Record
system
Ow System Location
15 "' Ub Quantity Pumped; gallons
t)ate of Pumping: ,7 �i ' �„�. � � 60
se)tic 'rarnk: No [_] Yes
Cesspool; No V?�7 Yes L_�
system Pumped by: ared0a
Liceoise#
Contents transl'errred to : Greater Lawrence serwttery INA1ct -
Date: __ —
Inspector
Col ()nweql(ll of Massachusetts
assac iuset S
fjystem Purnning Record
System Location
System Owner
0 C)
gallons
Date of 1111111ping:
Quafitity Pumped:
Yes L.
Cesspool: No Yes U Septic Tank: No
System pumped by: 97dredea License
Contents transrerrred to : Greater Lawrence Sanitar District
Inspector:
Date:
Commonwealth of Massachusetts
Massachusetts
y �em umpine� ec®r
System Owner System Location
Date of Pumping
Quantity Pumped: r(� r gallons
Cesspool: No'P7 Yes ❑ Septic Tank: No ❑ Yes
System Pumped by: 6444" License#
Contents transferrred to : Greater Lawrence 8anitary District
Date: Inspector:
r