HomeMy WebLinkAboutSeptic Pumping Slip - 125 BRIDGES LANE 1/6/2016 i
City/Town ommonw lth of Massachusetts
of R E /7M IE I V E l','° m r
System Pumping Record
Form 4
�.
DEP has provided this form for use.by local Boards of Health heriforms:rn:gtbsused, ut the
information must be substantially the same as that provided here. a ore using W06 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 hoes. e /righ side of hous , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under eck
Address r
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityirown Stat - Zip Code
Telephone Number -i
i
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 No If yes, was it cleaned? ❑ Yes ❑ No;
5. Condition of stem:
6. System Pumped By:
Neil Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location w re contents-were disposed:
L S. Lowell Waste Water
-C f 7
Sign t e ce Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record DEC 1 5 2009
Form 4
T0Q1 OF,NORTH ANDOVER
I
DEP has provided this form for use by local Boards of Health. Ot er ��FuWhavaaldT bus the
IL Fm-�-&-h I
information must be substantially the same as that provided here. ek" sing is 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 Locatipn-Ceift�side ight side of house, Left front of house, Right front of house,
0
Left rear of hoWRlg t rear Left rear of building. Right rear of building.
Address Is.
L-d UA'
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date C 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) E-Septic Tank ❑ Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2-<O If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of ystem: I
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
qgrptu'e-of Haul(/r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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 ruing out 1. System Location:
forms on the } ��
computer,use
only the tab key Address
to move your --
cursor-do not / uuu
use the-return Cityrrown State Zip Code
key.
2. System Owner-
Name
Address(if different from location
CityfTown
State ZCode
Telephone Number
.B. Pumping Record
1. Date-of Pumping pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank- ❑ Tight.Tank
❑ Other(describe): _
4. Effluent Tee Filter present? ❑ Yes 9-No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst em:
$. System Pumpei:By
L
Name + __
C ! Vehicle Lirznse Number
Gompany - -
7. Location where contents\Jeke disposed::
Sig 'u f auler Date
http://www.mass.govLd p/` to lapprovaIs/t5forms.htrn#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1
TOWN OF P"
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION °
kxb (example:left front of house)
Ro A- C
DATE OF PUMPING: QUANTITY PUMPED GALLONS
i
CESSPOOL: NO L, 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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED To: G.L.S.D Lowell Waste
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
w�
DATE: C
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
co t 0 (example: left front of house)
10-5 4+-DATE OF PUMPING:I b "i QUANTITY PUMPED ( Q 00 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: � r
COMMENTS:
CONTENTS TRANSFERRED TO:
('o,rrnionwealth of Massachusetts
�" . .. ,� ��'�Vlassacltusetts
§ystcm Pum p ir g Record
System (Jtvrrer System Location
99 uairtit Pumped: / gallons
Date of Pumping: t - 4 Y P
Cesspool: No Yes Septic Tank: No Yes
System I'rtrtrped by: vdrr'e'doa ,lfrel cww License #
Contents transferrred to IDistrict
Date: _ Inspector:
FORM 4 e SYSTEM PUN
D oF p
. 1
Commonwealth of Massachusetts
a
Massachusetts
System Pumping Record
--7v—stem vvner vstem Eocation
4u
Date of Pumping: 0 ' [ �Z Quantity Pumped: gallons
Cesspool: No Yes ❑ Septic Tank: No ❑ Yes J
System Pumped b.': - c� � _ License #:
Contents transferred to: ` ' 4
Date _ Inspector _