HomeMy WebLinkAboutSeptic Pumping Slip - 80 BRIDGES LANE 1/6/2016 Commonwealth of Massachusetts
z City/Town of
yi to pin Record
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/ tit front of hou 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
pb
Citylrown State Zip Code
2. System Owner:
RECEIVED -
Name'
Y 1 f3 201F
Address(if different from location)
°t°CN OF NOR I 14 MW r,e,TA*
• �1����i i�":i�a e u ,i
City/rown ' Stat
A
Telephone Number
r
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 resent?
p ❑ Yes o If yes, was it cleaned? E] Yes ❑ No;
5. Condition o stem: 4
6. System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
IF
Signittle qt Haule Date
t5form4.doc•06/03 1 System Pumping Record•Peg*a 1 of 1
Commonwealth of Massachusetts RECEIVE
= City/Town of
JUN 0 3 2013
YS to Pumping TOWN OF NORTH ANDOVER
Form HEALTH TNT
5 y
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, 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)
City/Town Stag ,�} ` Mode
Telephone Number
B. Pumping Record
1. Date of Pumping D t 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
tem:
5. Condition f_ � ar� U V
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises lnc
Company
7. Location where contents were disposed:
G L Lowell Waste Water
7 A SignAtufe I Haule Date
t5forrn4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
City/Town of 201 1
2011
System Pumping Record TOWN OF NoR�ri`l ANDOVER
L T
Form 4 OM
E
HALTH DEPART�iN'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 front of ho e, right front of house,]A side of house, right side of house, Left
rear of house, right rear of house,��-of-buikflnga—,-r(ii—aght rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town state 'Zl Code�
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Gallons
1 Type of system: F1 Cesspool(s) 8--§`e`pfic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. ConditioLl of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Loc * where contents were disposed:
L. D. L,4we11 ll W aAte_W_Qter
Signatu o Habler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
A
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 V 1. 4 2 D 07
DEP has provided this form for use by local Boards of H6%W I'l forms may be used, but the
information must be substantially the S"I'as-that*=11 efore using this forrn,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
Important:
When filling out 1. System Location:
forms on the �Av Use
computer,use
only the tab key Address
to move your
cursor-do not Cftyf rown State Zip Code
use the return
key.
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) .42-,Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-N-0---' If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
P
N [
6. System Pumped Y:
c)—r
Name Vehicle License Number
Company
7. Location where contents were disposed:
t5form4.doc•06/03 Signa�6re�"aier Date System Pumping Record-Page 1 of 1
Commonwealth of Massachuset ...
C ity/Town of I
System Pumping Record
Form 4 a:. C'k @.V
(�s��i��'�:�m�
DEP has provided this form for use by local Boards of Health. The Spy qMr 011�uimpingAecor� must
be submitted to the local Board of Health or other approving autho tSl
A. Facility Information
Important:
When computer,use
forms anl'theout System Location:
only the tab key Address
to move your
Cik fT own f' .. y ..t 1 �. Zip a
use the,return p Cod
cursor-d0 not City frown a
Code
key. 2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip—o-de'
Telephone Number
.B. Pumping Record
1. Date of Pumping Pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of t `� f
6. System P m ed.13
� y
p. µ "°� � /
Vehicle License
Name �.... Number
Company :. .
.7. Locati here ontents re osed:
Sign ture f auler Date
http://www.mass.gov/dep/w ter approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
RECEIVED
5 5
SYSTEM P PING RECO
1"OWN OF NCRTH ANDOVER
HEALTH DEPARTMENT
DATE: C
7
SYSTEM OWNER &a ADDRESS SYSTEM LOCATION
(example:left front of house)
1
� Y 6t kkts-�..
DATE OF PUMPING: ` I _ QUANTITY PUMPED : i "c'" GALLONS
CESSPOOL: NO YES PTIC 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:
NTS:
CONTENTS TRANSFERRED TO: G.L.S.® Lowell Waste