HomeMy WebLinkAboutSeptic Pumping Slip - 345 BERRY STREET 7/19/2017 vw..r'PlfxY1""N.'.p!
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Commonwealth of Massachusetts °° , °� �IVED
City/Town of
"�.�� �
System Pumping Record
Y
Farre 4 ���"� w�u�� iq��l��i6°i iN1�N�) '�°����
l En1'TF1 DEPA
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/Right rear of house, rig sif houses Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address 1 �—
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State r , Cpe
Telephone Number
B. Pumping Record
1, Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) C3-'Septic Tank [] Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o 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, 7G-i
at
ere contents were disposed:
LS. ' Lowed Waste Water
C"'
SignAtufe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of NO. ANDOVERJULI 02.01Z
System u m 1ng Record TOWN Of NORTH ANDOVER
- Form 4 H AL.Tf1 DEPARTMENT'
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information _..
Important:
When filling out 1, System'L0Cat1011"` ,
forms on the
Computer,use 345 BERRY ST
_ ..... . ....
only the tab key _Address- -
to move your NO. ANDOVERMA 01345
cursor-do not ..,......,
use the return City/Town State Zip Code
key. 2. System Owner:
� r
', DANIEL GC7111RE/ I1LT
d;
Name
re m n Address(if different from location)
_...... -- _._.. __......._..._-......._ .. �.__......—
city/Town State Zip Code
........ - .
......
--.. .... ....
Telephone Number
B. Pumping Record
1, date of Pumping ' ..... 2. Quantity Pumped: 1500
Date __
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank [) Tight Tank ❑ Grease Trap
❑ 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. CURRIERH79 406
....,_...... ._.._ .._ __.._---- . ........__.......,._ _,.,.
Name Vehicle License Number
J's SEPTIC & DRAIN
Company
i
7. Location where contents were disposed:
GLSD
�z 6/6/12
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/001 System Pumping Record• Page 1 of 1
Commonwealth of Massachusetts
A City/Town of NORTH ANDOVER, MASSACHUSETTS
R
System Pumping Record
7
r 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 author!ty"° _ . n...„
r,,. t„a V
A. Facility Information
Important: � vi 2 D 0 6
When filling out 1. System Location:
forms on the UMIII OF
computer, use 345 BERRY _STREETi j,
only the tab key Address
to move your
cursor-do not NORTH ANDOVER _ _ IMA sz n 5use the return City/Town State Zip odes
key. 2, System Owner:
"6 ,SEAN & DAN (3,011DREAU.LT
__ _
__.......
Name __._..,_..___..--.---._...
Address(if different from location)
City/Town State Zip Code
— -- -------------------
Telephone Number
B. Pumping Record
1. Date of Pumping $-/01 /06 2. Quantity Pumped: Gallons
6 0
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): -- —
4. Effluent Tee Filter present? E� Yes ❑ No If yes, was it cleaned? [R Yes ❑ No
5, Condition of System:
6. System Pumped By:
_RAGS,,S S ,PITC' SERVI(-"E
Name Vehicle License Number
Company
7. Location where contents were disposed:
WATER—S.(:IALT-IONS----GRCU&!...f..__T-AU.N-'�'CU---_ _ __._.....
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
REC ED
RE El ED
City/Town of C
System Pumping Record NOV 10 2009
Form 4
H ANDU'
TOWN OF NORTH ANDOI/E'
P E
L
JL 4:T
NT
F- A ji�iQ
DEP has provided this form for use by local Boards of Health. Other forrhs. he-
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health tri 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 Locatioink-L-6ft'-side a e, Right side of house, Left front of house, Right front of house,
ft
Left rear of house, ig�trear of house. Left rear of building. Right rear of building.
Address
City/Town State Zip Code
2. System Owner: (❑
Name
—-—------- —----------
Address(if different from location)
City/Town State zi ade
Telephone Number
B. Pumping Record (S
. . . (.0-
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) D--S�epfic Tank E] Tight Tank
n Other(describe): ------------_...__/__.._......_ ...................-
4. Effluent Tee Filter present? F] Yes 9-110If yes, was it cleaned? El Yes 0 No
5. Condition of System: ❑
�D 42--k A,
6. System Pumped By:
Neil Bateson F5821
..........
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location contents were disposed:
G.L.S.D Lowell Waste Water
Signature of Hauler Date
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
i W[i1�14 00 r d a V g 000-41 AS we-am M®VI
Commonwealth of Massachusetts
NORTH ANDOVER , Massachusetts
te ins Record
}stem aster }•stem Eocafion
JEAN & DAN GOUDERAULT 345 BERRY STREET
0 1 N: 2008
VOVMB
Date of Pumping: 8/21408 Quantity Pumped: 1500 gallons
Cesspool: No ® Yes . ® Septic Tank: To ❑ Yes
IAGGS SEPTIC SERVICE, INC. _
System Pumped by: d.b.a. E. A. COMEAU SEPTIC License ;
Contents transferred to: F''ITCHBURG 'TREATMENT PLANT
Date 8/21/08 Inspector RAGGS SEPTIC SERVICE, INC .
i
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TOWNOF NORTH ANDOVER
SYSTEM PUMPING RECORD
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