HomeMy WebLinkAboutSeptic Pumping Slip - 116 BRIDGES LANE 1/6/2016 Commonwealth of Massachusetts
City/Town of ECEIV E
h v E
System Pumping-Record
Form 4 �Q. 8
SOWN OF N¢.7RDAMD(.VE
DEP has provided this form for usezby local Boards of Health. Other form0PgyiWusedy1.qt 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 �ronofsbu�1. System Location: Left i ht fr Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rigilding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
• CitylTown • State ,,.dip Code ;
t
I5
Telephone Number
i
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Ic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ® o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition o System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
I
7. Locati here contents-were disposed:
G L S: Lowell Waste Water
--- - L'
Sign a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
RECEIVED
Commonwealth of Massachusetts
City/Town of r m '01,
Sys' tem Pumping Record HEA a Na`W: e 1"Jq O'V[,ji
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 Ahis 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 Riaht front of house Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
( lQsav
City/Town state Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown ' State Gf Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ( ;/2. uantity Pumped: Gallons `�' �)
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
I
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [(No If yes,was it cleaned? ❑ Yes ❑ No
I
5. Condition of System:
KV-i kn cl �-e�j ef
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here contents were disposed:
�G-LL S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06103 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of
System u i Record
I UFA - Form 4 -)F a 1 THANL)
HE
LTH
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
Important: •
When filling out 1. System Location: Left front, left rear, left side of hous . Rij front,, fight rear, right side of house.
forms on the
computer,use
only the tab key Address
to move your wc
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
4 A �11 Avt4' b
Name
Address(if different from location)
Cityrrown State (� ( Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ock 2. uantity Pumped: 1 SO
Date Gallons
3. Type of system: Cesspool(s) Septic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? 8 Yes �' No If yes, was it cleaned? 0 Yes No
5. Condition of System: r I
6. System Pumped By:
_Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
I
7. Location-w a contents were disposed:
L.S.D Lowell Waste Water
70
igna ure of H u r Date
t5form4.doca 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. 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 front of hous,�, 4rij� front o�fh,;Zls left side of house, right side of house, Left
s 0�
u
rear of house, right rear of house, le si e o uilding, right rear of building, under deck.
City/Town • State Zip Code
.2. System Owner:
Name
Address(if different from location)
City/Town State 17
7"1'
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) [A"'Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ElNo If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi o System: j
G
6: System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Lqpaf wherp contents were disposed:
G.L.S. . ALowell"steWpter
9' � Date
7 --- 7, ((
Signa u of uler
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
k)6rl l\
TOWN OFX ANDOVER
SEPTIC SYSTEM SERVICING
REPORT
Date: � r
Homeowner:_ 6 Pumper
Ae
Street "[P �° �, Address:_� - V--,
Phone Cp 1 - 7 ` Phone _ 6c�' 1
.................
Nature of &.rvice: Routine
Emergency
Observations: Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Description of Work:
Comments:
1
u