HomeMy WebLinkAboutSeptic Pumping Slip - 531 FOREST STREET 6/29/2016 �m
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$OLrO CA KA YOYVR"-" EXPLAIN
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Commonwealth Of Massachusetts
City/Town of NORTH AN-DOVER MASSACHUSE T
System in� cor
Form 4
BEP has provided this form for use by local Boards of Health. The 10fir"ou A g lie ord mut
be submitted to the local Board of Health or rather approving at Ithority.
A. Facility information -
Important: Town of NORTH ANDOVER
When filling out I. System Location: HEALTH DEPARTMENT
(arms on the -
computer,use
only the tab key
to move your
cursor-do not -------—— .._
use the return Cltyffown - -- — - State
key. 7_ip Gode
2. System Owner:
Name
Address(If different from locatiart)—..—_. ._ „--".'.--� - -•—_-.,—•.---_.
CitylTown ��.—_--�..—__.—..�_—_.� state ....__. _ -•-------•
Zip Code
• c'
Telephone Number — — __.------..,
B B. �'urrlping Rcord - 11
I. Date of Pumping — 1 CP�V __ 2. Quantity �
Date ty Pumped: Galians
3. ype of system: ❑ Cesspool(s) e tic Tank
-, p ❑ Tight Tank
❑ Other(describe);
4. Effluent Tee Filter present? ❑ yesf4 If yes, was it cleaned?
❑ Yes ❑ No
e�5 I
Conditio ff ssystem:
6. Sy em Pumped�By:
ame
company
7. location where contents were disposed:
Sy ature of Hau '�� % ___.._.._. _-_-_—_._. '�✓ i �v /�/
loafs — -V .._------ ..,..__
http://www.mass.gov/dep/water/dP'proval$/(5forms.htm#inspect
t5form4.doc+()6/03
system Pumping Record+page t of t
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Pp�INO REC0FD
DATA QUA e, oL a
1
SYSTI~M OWNER&ADDR)3SS SYSTEM LOCATION ~
n blow :_..:
Al0 • -AAo6 ei f
. v �., lea••
DATE OIL PUW]N fl�•:
Q QUANTITY'PUMPEU f .0
CESSPOOL NO �J gEpTtC'`ANK NO
NATURE OF SJ3RVICR;;,RQy _'MME Q
' , � .•� R ENCY,�
OBBBRYATIONS:-. .'. :r; .. ,.. .
' a00D CONDITION'',� F . PULL TO CO,VER
- FRI$0Y ORBASE ;` t DAIrF1,}3S IN LACH
; • _ LI3ACHFMLD XVNEACK
?3xcMSIYE S0LW ' •FLOIQQHD
SM)CARYOwI OTHWR WLMN - -�
,.. SYMM PUMPED 13Y
COMMMI? Sf' ivc
COMMNTS TRANSFERR$1)
FORM 4 - SYSTEM PUMPING RECORD
Conrmuvrealth of Massachusetts
North Andover, Massachusetts
System PuMRing Record
System Ovmer System Location
Christopher & Tanya Joblon front yard
531 Forest Street
North Andover
Date of Pumping: May 20, 1996 Quantity Pumped: 1000 gallons
Cesspool: No /—X/ Yes /—/ Septic Tank: No /—/ Yes Iii/
System Pumped by: Service Pumping & Drain Co. , Inc. License $ 636
Contents transferred to: Lawrence Treatment Plant
Date: May 20, 1996 Pumper: J.N.
This is PROPRXETARY and CONFIDENTIAL J.nfo=mtion which may be used
only by the Board of Health for regulatory purposes,