HomeMy WebLinkAboutMiscellaneous - 149 BRIDGES LANE 1/6/2016 Commonwealth of Massachusetts ° RECEIVED
m'
4 City/Town of
System Pumping Record j:''JV . 13
4
Form
.i"oWvII OF D i��i;n�i i J!,6i)OVER
DEP has provided this form for use by local Boards of Health. Other rms may tie u es d, 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 h �ofho e, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left building, Under deck
Address
� \
Cityrrown State Zip Code
2. System Owner:
Name*
Address(if different from location)
City/Town Statea 9 jZip Code
Telephone Number
B. Pumping Record
M'=�
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.
f S
5. Condition ystem:)
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio where contents were disposed:
L S. Lowell Waste Water
SlgnAtufe qt Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record �� �� `
Form 4 TOWN
iai.,�t.T��.�i t�.�NwE�r�ART'EVENT
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 side of house, Right side of house, Left front of house, Right front of house,
Left rear of hour , iglu rear of house-4eft rear of building. Right rear of building.
Address
Cityrrown U State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ,�2. uantity Pumped: Gallons So
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
i
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiorrwfi re contents were disposed:
LAS.D Lowell Waste Water
lygrptute of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
Commonwealth of Massachusetts
City/Town of
,/ WN NORTH ANDOVER
System 1 Record TOWN LrH DEPARTMENT
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 tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health mother approving authority.
A. Facility Information
1. System Location: L e of house, Right side of house, Left front of house, Right front of house,
Left rear of hous Righ r ar of hou Left rear of building. Right rear of building.
Address
Cityrrown State Zip Code
2. System Owner: ❑ j� �
Name
Address(if different from location)
City/Town StatV �i — �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 o 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. Locati a contents were disposed:
L.S.D Low II tow ter
Signature f le Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Coinmonwoalth of Massachusetts
City/Town of i EIS
a b System Pumping r
Form OO ' 1 ,12008
DEP has provided this form for use by local Boards of Health. O h 6Odb t the
information must be substantially the same as that provided her . eck 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 Loca 'on: Left front, left rear, left side of house. Right front, right rear, right side of house.
forms on the
computer,use
only the tab key Address � ,A,( J
to move your U`
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
-- Name
Address(if different from location)
City/Town State �/j --C �`Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) - Septic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes f No If yes, was it cleaned? Yes ( No
5. Condi 'o\01 System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ere contents were disposed:
L. D Lowell Waste Water
igna ure of H"r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
°4
OCT 2 4 2006
RECEIVED Commonwealth of Massachusetts City/Town of I c r y to umpin vtvl Form 4 M NT
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 filling out 1. System ocatio
forms on the \ ?
computer,use ttt r
only the tab key Address },
to move your Gik Row t , ;„..�a,
cursor-do not _
use the-return y n State Zip Code
key.
2. System Owner: �/ g
Name
�I
Address(if different from location)
City/Town Stat
p 6"- Code
Telephone umber
B. Pumping Record
r _ C
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? F] Yes n' lo.e If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systte�:
6. System P mp By -`�,
Name Vehicle License Number
Company
7. Locatio re ontent re di sed:
i
_. e -
Sign re H uler Date
http://www.mass.gov/dep/water/.approvals/t5forms.htm#inspect
t5form4.doc•06/03 System'Pumping Re,I cord-Page 1 of 1 j
i
Commonwealth of Massachusetts
Massachusetts
2004
,.. „....,.,,w.„ '
System Owner System Location
Date of Pumping: (�' "1” Q Quantity Pumped: 1 ':SOC) gallons
Cesspool: No Yes [] Septic'Tank: No [] Yes [
System Pumped by: " saavnaw License #
Contents transferred to: Greater Lawrence Sanitary i tri
Date: C) ` ,;�� ° Inspector:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 5`"30-®off
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
LrC,4,
DATE OF PUMPING: -00—QUANTITY PUMPED t Sc;�) GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE YIEMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
4�)
Commonwealth of Massachusetts
A) , Al-�a)(OrMassad iu set(s
Svstem Pumvinu
System Owner System Location
(l
Date of Pumping: �- uaittity Pumped: gallons
Cesspool: No Yes Septic 'I'artk: No Yes
System Pumped by: vare4art ri med License #
Contents transferrred to : Greater Lawrence Sanitary yistrtct
Date: ----- --- Inspector
err