HomeMy WebLinkAboutSeptic Pumping Slip - 137 BRIDGES LANE 1/6/2016 Commonwealth of Massachusetts
City/Town of
System Pumping cor .C1
Form 4 TOWN U-rwR a M Asvi:aOVER
HEALTH DEPARTMENT
if ME
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 4Q_rear Left/right side of house, Left/
Right side of building, Left i Right front of building, Left/Right rear of building, Under deck
Address
F30 E�5
Cityfrown ° \ State Zip Code
2. System Owner:
Name
Address(if different from location) j
CityRown ' State Zip Cow
f � � 4
Telephone Number
i
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic
e Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L3'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' ere contents were disposed:
GLL S. Lowell Waste Water
_0
Signgtufe ct Haule Date
t5form4.doc•06/03 System Pumpin g •Record Page 1 of 1
9
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i
wM. CF I VE 1,)-,w� .,�
Commonwealth of Massachusetts
h W City/Town of
System Pumping r
i I' y�ivwu".°::`d a^a 9W'i t"^i��tlJVd„
Form 4 HEALTH
TH L�i� w�
• �, ���a
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 kit rear.nt ham , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
CitylTown State — �Z Co de
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 0-Co If yes,was it cleaned? ❑ Yes ❑ Na
5. Conditi n of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign toe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
1�
Commonwealth of Massachusetts V;2YD -
City/Town of
y t u i c r Form 4� TO,VVfN F NORTH AHEALTH C.DEP DEP has provided this form for use by local Boards of Health. Other fo�r� -may°b
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 fron lgh 'rear ight side of house.
forms on the r_
computer,use C
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 Zip Code
Telephone Number ;
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: p Cesspool(s) /Se/ptic Tank El Tight Tank
[j Other(describe):
4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? Q Yes Q No
5. Condition of System: h
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of I LC ED
System Pumping Record
yr, Form 4 DEP has provided this form for use by local Boards of Health. AMNDOVER
tRec rd must
be submitted to the local Board of Health or other approving aut
A. Facility Information
Important:
When filling out 1. System Location:
forms on the 1 '�-' ._ .. �t h4qu�
computer,use
only the tab key Address
to move your
cursor-do not
City/Town
use th&return State Zip Code
.key.
System Owner:
Name
Rte! Address(if different from location)
City/Town State `
l C
Telephone Number
B. Pumping Record
1. Date.of Pumping g Date 2. Quantity`Pumped: Gallons
3. Type of system: Q Cesspool(s) U-Septic Tank ❑ Tight.Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑moo^ f If es was it cleaned?
Y ❑ Yes ❑ No
5. Condition of stem
/pp :
6. Syste Pu ped,By y
:Name Vehicle License Number
a
Company
.7. Location ere content ere dftosed:
Signat e o au r Date
http://www.mass.gov.tdep a r/a provals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
° Commonwealth of Massachusetts
�1 Massachusetts ..
�' 2004
if': ,r r M ji
PA
System Pumping Record
System Owner System Location
Date of Pumping: to—CCC Quantity Pumped: c gallons
Cesspool: No [ "Yes [] Septic'Tank: No [] Yes
System Pumped by: Fa&"W oggaolzw License#
Contents transferred to: Greater Lawrence Sanitary i tric
Date: 10 -A CJ Inspector:� P
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: tQ O'-per
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
(example: left front of house)
, 14-- ;— 6
C1 C-5 Ln _ �,
DATE OF PUMPING: 10-30-0 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: �
COMMENTS:
CONTENTS TRANSFERRED TO: LourI,
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
Date of Pumping: t m l 9- Quantity Pumped: /1'9�e_-gallons
Cesspool: No Yes Septic Tank: No Yes
System Pumped by: lga&d" Fa&qn&e4 License#
Contents transferred to: Greater Lawrence Sanitary District
Date: —inspector: