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Home My WebLink AboutSeptic Pumping Slip - 158 OLYMPIC LANE 6/9/2016 Cornmonwealth of Massachusetts ti City/1"own of NO. ANDOVER System Purnping Record F orrn q �r DEP has provided this form for use by local Boards of �� I" .b. t.lsed, but the information rrmst the substantially the same as that provided here. Before: using this form, check with your local Board of Flealth to determine the form they use. The SysterTI Pumping Record must be subrnil:ted to the local hoard of Health or other approving authority, A. Facility Inforination Important: When filling out 1. System Location: forms can the compauter,use '158 OLYMPIC L11 only the tab Ivey Address _ to move your NO. ANDOVER {VA 0'1845 cursor-do not -- - ---- - — use the return City/'rown State Zip Code key. 2. Systern Owner- -.. I Name _- - - u n Address(if different from location) — .._ _....._ _..... - _ _.-- -- -- city/1-own State Zip Code --f -_— . relepahone Number B. Pumping Record 9/3(1/11 1200 1. Date of Pumping -c��te 2. C.1t.raratity PUrraped: Caac�r7. _ 3. Type of systern: I. _] Cesspool(s) [w eptic Tank �_) l irlht Tank Other (describe): 4. Effluent Tee Filter present? Yes V- NO If yes, was it cleaned? r�I Yes [I No 5. Condition of System: C. Systern Pumped By: Jarnes H. Currier H79 406 Name Vehicle Lieemse Number J's Septic& Drain — ....._ Company 7. Location where contents were dispensed: .� � .. 9/30/11 Sig r7ata.rre:ofI-laraler Bate, t5form4.doc«06/03 System Pumping Record«Page 1 of 1 ❑ Cornm riwea h of MassaGhusetts FV«u❑ n -Yt City/1-own f ANDOVER �u f l, System ven ()VV tku c1 c, + a tl f AND(W DEP has provided this foram for use by local Boards of Health. Oil, , E T information must be substantially the same as that provided here. T ch ck with your local Board of Health to determine the form they use. The System Pum ing f ecof- ml ust ue submitted to the local Board of Health or other approving authority. A. Facility Information _ --- Important: When filling out 1. System Location: forms on the computer,use 155 OLYMPIC LANE _ _ _ only the tab key Address to move your NO. ANDOVER MA 0,1545 cursor-do not use the return City/Town State Zip Code key. 2. System Owner: �r THOMAS THROOP -- Name – -- E__1 Address of different from location) City/Town State Zip Code B. Telelahone NuY�ber — Pumping car -- - 9/ 5/10 '1200 1. Date of Puhnping _ Z1,3( Quantity Pumped: - -----_ ___. Date ...Gallons 3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Ti ht Tank g ❑ Other (describe): - - 4. Effluent Tee Filter present? ❑ Yes /No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: James h-I. Currier 1-179406 Name Vehicle License Number J's Septic & Drain Company 7. Location where contents were disposed: GLSD 9/23/10 Signat�le of Hauler pate t5form4.doc.06/03 System Pumping Record•Page 1 of 1 w Gormnonwealt[i of Massachusetts RECEIVED City[Town of NO. ANDOVER &J PSG B, �0( 9 rt°rt 4 T wt,4 OF t,K)rT H ANOOVER H EA I r t DEFIA R.l.rwEN F DPP has provided this form for use by local Boards of Health. Otlijrlarms''mnybe-wursrd,,°,but4fie 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. Systern Location: forms on the computer,use 158 OLYMPl LANE only the tab key Address to move your NO. ANDOVER MA 01845 cursor-do not _ -- - Cil /Town _ use the return City/Town Zip Code key. 2. System Owner: X11THOMAS THROOP Name rerun Address(if different from location) City/Town State Zip Code _- _.._ . Telephone Number B. Pumping score - 5/22/09 1200 1. Date of Purnping Date -- 2. Quantity Purnped: --- - Gallons 3. Type of system: El Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): _ _ . 4. Effluent Tee Filter present? ❑ Yes IT No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: C. Systern Pumped By: Benjamin Shute 1°°I79 400 Name Vehicle License Number J's Septic & Drain Company - 7. Location where contents were disposed: GLSD . 5/22/09 -- - _ e g Nauler Date t6fonnel.doca 06/03 C✓ system Pumping Record«Page 1 of 1 City/Tom of NO. ANDOVER Systei Form "OWN, D ID has provided this forma for use by local Boards of Flealth. Other fort xa rrt y'bae tared, but ifke" information must be substantially the same as that provided hare. Before rasing this form, check with your local Board of Health to deterrnine the form they rase. The System Purnping Record must be submitted to the local Board of Health or other approving authority. A. Facility Inforination Important: When filling cant 1. System Location: forms on the t_YMPIC 1_ANF� computer,aa.aa; '158 (�... _ only the tat)key Address to rrrove your NO. ANDOVER 11 A 0'184 cursor-do not __ _ City/Town/Town use the return Y Slate Zip Code key, . System Owner; THOMAS THF2OOP Name ervn Address(if different frorn location) City/Town State Zip Code ----_ __ telephone Ntarnber B. Pumping Record 5/5/08 1200 1. Date of Pumping - 2. (. Vantity Purrrped: - --- bate Gallons 8. Type of system: (.� Gesspool(s) fpk ;peptic Tank Tight Tank ❑ Other(describe): --- - ,s, 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Systerra Pumped Fay: Benjamin Shute H79 406 --- — - _- - -- .........._.... ...... Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD d 5/5/08 ee "° r �� Gate t e t5form4.doc.06/03 System Pumping Record•Page 1 of 1 r � nwea l r of shag u z City/ I O E System Pumpirig Record Form ni DB.P has provided this form for use by Iocal Boards of Health. Other forms may be used, but the information must be substantially the satire as that provided hero. Before ttsirrg this form, chock with your local Board of Health to determine the form they use. The Systern Pumping Record roust be subs-pitted to the local Board of Health or other approving authority. A. Facilfty Information Important: �� w.. When filling out 1. Systern Location: fanris an the computer,use 1 OLYMPIC LAND ------ tyr ri l I�rf;E 4 6 i�C tt'�Iki� only the tab key Address- - f fLd to move your N ANDC7\/ L 01 845 cursor-do not use the return City/Town State Zip Code key. 2. Systern Owner: THOMAS THROOP -__ __. Nance - Address(if different from location) City/Town state Zip Cade Telephorie Nurnber B. Pumping Record 6/14107 1200 1. Date of Purnping 2. Quantity Pumped: _ ....... ..... Cate Gallons 3. Type of systerrl: (,J Gesspool(s) NJ Septic Tank ❑ Tight Tank ❑ Other (describe): ----- ._ --._ __ 4. Effluent Tee Filter present? El Yes �''No If yes, was it cleaned? [_� Yes No tip. Condition of System: j 6. System Pumped By: Benjamin Shute H79 406 Name Vehicle License Number J's Septic & Drain Company 7. Location where contents were disposed: GLSD �r —�- ---- --- -- 611 4107 n e Date - t5forrrAdoc•06/03 Systerrr Pumping Record•Page 1 of 1 .i ,w R it P V, O iano ealth of sachU ye a t r — �i /u c ui of NO. ANDOVER 1 Sys tern l i w "r rt-n ; DEP has provided this farm for use by local Boards of Health. Other forms may be rued, but the information must be substantially the same as that provided here;. Before using this form, check with YOUr local Board of I--iealth to determine the farm they use. The System Pumping Record roust be submitted to the local Board of Health or other approving authority. A. Facility Information — ----- — Important: When filling out 1. System Location: forms on the computer,use t5F1 OLYCUIC'1C� LANE__._ - - - - ...._..........— only the tar)key Address to move your NO. ANDOVER CUM 01845 cursor-do not — use the return City/Town State Zip Code key. . System Owner: tab THOMAS THROOP Name - 6-11111 Address(if different froirr Ioc anon) — - city/Town State Zip Code Telep)one Number B. Pumping cr 0/8/0b 1; 00 1. Date of I�urnping -rate ._ 2. Quantity Pumped: GIallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank [__I Other(describe): - - __ -— - 4. Effluent Tee Filter present? ❑ Yes W No If yes, was it cleaned? "Yes ❑ No 5. Condition of System: 6. System Pumped Cry: Benjamin :chute H79 406 Nairn Vehicle License Number QC's Septic& Drain Company 1. Location where contents were disposed: GLSC7 - - atr of Sul r Date t5forrn4,doc•016/03 Systern Pumping Record.r'at'e 1 of'l FORM 4-SYSTEM PUMPING RECORD Commonwealth of Massachusetts Massachusetts Svstem -Nmvine Record ystem wmer ystemn Location REd -fVE , �' ,r. HEALTH Type: Emergency ❑ Routine [ Cesspool: No 'Yes ❑ Septic Tank: No Yes Date of Pumping: ; iV' Quantity Pumped: dJ gallons System Pumped by (Company) 4 Permit #: Contents transferred to: Contents disposed at: Date - Pumper Si natur Condition of system/other comments: al DEP APPROVED FORM-12/07/95 FO -,SYSTM PLWImG woRD Commonwealth of se 6 Massachusetts .er yst watzon b Type: Emergency ® Routine ET"""" Cesspool. No � Yes El Septic Tank- No El Yes . , Date of Pumping. ,J_.. )-& O;:3 QmntitY Pumped-- / (1 0 ,gallons System Pumped by (Company). Permit 9. Contents transferred to- -Contents disposed at. Date Signature 1 Condition of system/other comments: SDEEEt&'MOVE1D FORM- 2107195 FORM 4 o SYSTEM PUMPING RECORD Commonwealth of Massachusetts Massachusetts System ,Pumping Record ystem Owner System ocation Type: Emergency ❑ Routine Cesspool: No Yes ❑ Septic Tank: No ❑ Yes Date of Pumping: G,&' &z Quantity-Pumped: / 9-0 gallons System Pumped by (Company): F A41 Permit n: Contents transferred to: Contents disposed at: L sJ Date Pumper Signature Condition of systen/other comments: DEP APPROVED FORM-12/07/95 Form 4 -.. rystern Pumping Record Commonwealth of Mossachusetss Massachusetts &stem Purnoina Record System nsr System Location W Type. � y Routine Cesspool: NIO Yes Septic tank: No OYes Date of Pumping: "' Quantity Pumped: � Gallons System Pumped By: Wind River Eaviponmental, LLG" Permit Contents transferred to: Contents Disposed at: Nate: Pumper Signature: Condition of Systeffrl�h-ercolments DeP AP ved F ret - 1 x/07 Porin 4 _.. System Pumping Record Commonwealth of Mossachusetss : Massachusetts stem Pum 6 Record System Owner System Location ',frr I,J,>i e`�6/,.E,*11Y�t*,'�,,_,-f twd, � 1�„,. 1,"„ss✓�i va,^f4fr.l4 r,r�,➢. r1L�ki1 � ,t7, h Z, 1,`24,, i.i,. �? lfll,', ✓„i ;r, Type: Emergency Routine Cesspool: NO Yes Septic tank: hlo W `des orate of Pumping: � Quantity Pumped: Ions System Pumped By: Wind River E'nwilynowntal, IW Permit : l' � Contents transfer to: Contents bispo at: Gate: Pumper Signature: Condition of System/Other Comments i ,pep Appraraved From - IZ107/9'x' 9 o FORM 4 - SYSTEM PUMPING RECORD II SEPTIC Y 107 FOREST"STREET;MIDDLETON,MA.01949 (978) 774-2772 COMMONWEALTIT OF MASSACHUSETTS A�kel '1/ a' 'MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER' SYSTEM LOCATION: 0 u e n x � y l 3 DATE OF PUMPING: 4/_ /0 " 0 0 QUANTITY PUMPED: /�5—0 0 GALLONS CESSPOOL: NO 0 YES 0 SEPTIC TANK.: NO YES SYSTEM PUMPED EY: —UIR IGnR I,P 11 DRAIN SERVICE+J CONTENTS TRANSFERRED TO: ' z DATE: %°/°C� _ INSPECTOR: 4 d "` �0 1