HomeMy WebLinkAboutSeptic Pumping Slip - 161 BRIDGES LANE 1/6/2016 Commonwealth u .
City/Town of
System Pumping Reco
r d 1
Form 4 t� ti
DEP has provided this ford for use4by local Boards of Health. Other f®rrn' 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 housdjLe fight ear of , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown state Zip Code
2. System Owner: /, I o�����,(
Name'
Address(if different from location)
Cityrrown State ip Code
Telephone Number
1
t
t.
B. Pumping Record
1. Date of Pumping � . --
p g 2uanti Date 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:
Neil Bateson F5821
Name vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' 5Hiaule ntents-were disposed:
G L SLowell Waste Water
sign t e Date
t5forrM.doo•08103 System Pumping Record.Page 1 of 1
I
s
Commonwealth of Massachusetts f
City/Town of o
Jw: � °
S item Pumping Record
orm 4
F
. u
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, -nigh �parof house;f'eft/right side of house, Left/
Right side of building, Left/Right front of building, Left/ rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner: r
Name
Address(if different from location)
i
Cityfrown State Zip Code
,%f ((
Telephone Number
B. Pumping Record
1. Date of Pumping �' _f 2 "Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) 07Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
via ve
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locaferf viifiere contents were disposed:
L Lowell Waste Water
Signkufe cfHauleV Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
a
System iii ' .
y` Form
"4
TOW OF NORI+l AN D VE.P
DEP has provided this form for use by local Boards of Health. Other for Vii.
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 orotber approving authority.
A. Facility Information
1. Este, mLocation: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of housight rear of house. Left rear of building. Right rear of building.
Address
t _ 4✓ ViaC�~wJ
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
i
I
City/Town State )C ode_
Telephone Number t
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 Ls 'rvo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 1
1
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio vuhe a contents were disposed:
G.L.S.D Lowel to Water
Signature f H ule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
J�~,
,~y, ��
" ~^""nw ��,
System Pumping Record
Form 4
DEP has provided this form for use bvlocal
Boards of n ' butthe infnrnation must ba substantially the same oo that p Z:Jform, cheoh
with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted ho
the local Board ofHealth or other approving
�
authority.
A. Facility Information
1- System Location: Left front of house, right fro
rear of house, right rear of house, left side of building, right rear of building, under deck Lf �e
2. System O�nar�
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -6a—te 2. Quantity Pumped:
3. Type of system: E] Cesspool(s)
Septic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Ej Yes r-114o |f yes, was iLcleaned? F7 Tea 0 No
5. Condition of Gyotern�
� O
8. System Pumped By: �
Neil J. 8ahaoon
F5821
Name
Bateoon Enterprises Inc. L--'-N—m--
Company
7. Location where contents were disposed:
Signature'v'7r'~'< oom |
/
t5form �c-06/03
System �
'
Commonwealth of Massachusetts `�W
City/Town of
a System Pumping ecor DEC 0 4 2009
Form 4
s ()�J�k 6 t dfb CGFIME�' 1 .i°�
..0 Q V d limmi.�"94'C W f66...8w&i
DEP has provided this form for use by local Boards of Health. Ot Yer1' rs ray tie tted, um 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
Important:
When filling out 1. System Location: Left front, left rear, left side of house. Right front, right re r, right side of house
forms on the
computer,use
only the tab key Address
to move your
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
VQ
Name
Address(if different from location)
City/Town State , Code
� I' — 1
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ] Cesspool(s) ___ eptic Tank rl Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes If yes, was it cleaned? Q Yes No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Q.L.S.D Lowell Waste Water
V1 0')j-- Z ( _
igna ure of H"r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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DER.has provided this form for use by local Boards of Weait . They ystem Pumping Record must
be submitted to the local Board of Wealth or other approving a�tpp f,f <�
A: Facility ,information
;� When filunp out I'. System Location
,; 6hnb,on the`
computer,use,
only the tab key Address
to move your
' use ththe,d tumt. Cityfrown State Zip Code'
i key a)C r8 +1 ,''�� `�
2
Sys tem Ownet: r
,
a Name
Address if different from location)
CityfTown State- Zip ode
Telephone Number
limping Record
w� µ�" •
I.:,' ' bate,of Pump�in �' `
P g Date 2, Quantity Pumped; Galioris
Y ,
T m: ® - Cesspaol(s) Septic Tank ❑ Tight Tank
ype of s ste
®"Other(describe);
4, Effluent Tee Filtertpresent?.❑ Yes. o' If yes, was it cleaned? E3 Yes ® No
i}
Caitdition of System:`:
r
6, Sy enJ Pumped By'
Vehicle Llcenoe Number
ty t � �Y�"iT i " l,rr�l�f��+�5r+f ;�ih I�ld4 // / y,,.♦ h�''�. �f�f,
co
+ y�,1s rant aTry�a ,d;', r Sal.f 1.•; t �"� ��
7. `Location where contents yver`e disposed:
t
�� ,`.:' s• `�1 ° S at aulef, �t '� Date
tip. w mass gov/dep/dater/apprCvalslt5forms,htm#inspect
t5fornAdocs 08/09 y tem Pumping S s Record Page 1 of 1
:.
TOWN O NORTH ANDOVER
uA ft
SYSTE PUMPING} RECORD
SYSTEM OWNER dt ADDRESS SYSTEM LOCATION
rig
Ov o olv& vet, muq
DATE OF PLJWNQ: -
;_.. Qt.1A1JTiTY PUMPED:
�tSSPOUL: NO YES
-_..... .. ...... Saptic Tank: NU YES
NA f URb OF SERVICE: ROUTINE, EM!✓RUENC'1'
ubsbRVA'rIONS: 7 2001,
0000 CONDI'rIUN
!FULL To o COVER
HEAVY ORWE SAF.FI.,ES IN PLAU,
ROOTS _..__. LBACHFlELD RUNBACK
8XCUSIVE SOLIDS FLOODED
SOLID CAl(RYOVER,�.,OTHER EXPLAIN
5ystsm Rum d by
t.'0MMENTJ.
rlrNTS rKANSF'I;RRfiu rc) go
�-
r
TOWN OFN04TH ANDOVER
p, q SYSTEM PLJMplNG RECORD
DATE_
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
p
DATE OF PUMPING Z j TQUANTITY PUMPED c7 C7
CESSPOOL NO ZysS_ SEPTIC TANK NO YES
NATURE OF SERVICE,',RQUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS I LEACHFIELD RUNBACK
EXCESSIVE SOLIDS -FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY
COMMENTS:
CONTENTS TRANSFERRED TO
. TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 7 F
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING:
QUANTITY PUMPED ;
GALLONS
CESSPOOL; NO �YES
SEPTIC TANK: NO ___ YES
NATURE OF SERVICE; ROUTINE
--__ EMERGENCY
i
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE FULL TO COVER
ROOTS ------ BAFFLES IN PLACE
EXCESSIVE SOLIDS LEACHFIELD RUNBACK '—
SOLIDS CARRYOVER FLOODED ------
OTHER (EXPLAIN)
SYSTEM PUMPED BY:
OMMENTS: :; w w
its
0 NTENTS TRANSFERRED TO: