HomeMy WebLinkAboutSeptic Pumping Slip - 150 BRIDGES LANE 1/6/2016 Commonwealth of Massachusetts
= City/Town of
y* to Pumping, rd
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 fious L /Right r o house)Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address .y l�`�t""� Cam"❑'„,�.._. •Cts"'� '�°"�"�4... _. '
Cityfrown state
2. System Owner. O
Name' idER
LT 'i Eft 11ANDOVERY
�4 TMENT
Address(if different from location)
City/Town ' State ,� �,� ,.,Zip Code/
Telephone Number
r
B. Pumping Record
1. Date of Pumping 2. Quantity 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 Sy�e✓i-tiG t (� ❑ � � .
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
LS-Q LS-Q Lowell Waste Water
14 .7 � -
Signitufe 9t Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts h r`
City/Town of
stem Pumpin Record ���^� � .r `
Y
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(( /Rightd"ear of house. Left/right side of house, Left/
Right side of building, Left/Right front of buTding, Left/Right rear of building, Under deck
Address y, "�, L—v\ /Vc ` `"°° a'
City/rown ( (J State Zip Code
2. System Owner:
Name
I
Address(if different from location)
Citylrown State Zip Code
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 present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No.
5. Conditio Ustem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio_ where contents were disposed:
a S: Lowell Waste Water
/ / ( ✓
Signitufe Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
M Vey
ro
DEP has provided this form'for use by local Boards of Health. Other f6mi.s 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 hoes , e /Righar of hous Left/right side of house, Left/
Right side of building, Left/Right front of b i ding, Left/Right Pear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner: PLO--e-o e—��
Name
Address(if different from location)
I
City/Town State ip Code
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 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. Locaf ere contents were disposed:
G.L Lowell Waste Water
J� —
Sign toe Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
T
1
Commonwealth of Massachusetts
CitytTown of RE WED
System r
Form 4 °w m
DEP has provided this form for use by local Boards of Health. Othe f6 c
information must be substantially the some as that provided here. 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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
)ortant:
en filling out 1. System Location:
ns on the
nputer,use w
f the tab key 'Address
nova your North Andover ma 01886
nor-do not Cityrrown State Zip Coda
the return
2' System Owner:
Name
Address(if different from location)
City/Town state Zip Code
Telephone Number
B. Pumping Record
f r
1. Date of Pumping / 2. Quantity Pumped: Gal
crate
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
oo
6. tam Pump�$y:
�m
Name Vehicle Ucense Number
Stewart Septic Service
Company
7. L o where contents were disposed:
to its Pre treatment Plant 20 So. Mill St Bradford Ma 01835
{ I D, C_
re of Hauler Date
Signature of Receiving Facility Date
arrrk doc-OW06 System Pumping Record•Page 1 of 1
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be tem Pumping Recorc _,
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TOWN OF NORTH AN-DOVER
SYSTEM PUMPING RECOR- ►
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
/Vd
DATE OF PUMPING: --dpLQUANTITY PUMPED �CALLONS
(,'1�'SSJ1OOL: 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:
C'UNINI EIN T S:
c0NTI,-'N'I'S TRANSFERRED TO:
r�
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house), /
DATE OF PUMPING: "/k/a QUANTITY PUMPED / 00 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY_
i
OBSERVATIONS:
GOOD CONDITION ✓ FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: An 0/0cv r
i
1
I
COMMENTS:
i
CONTENTS TRANSFERRED TO:
C
,�,y�ov�