Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 67 ROCKY BROOK ROAD 12/1/2017 Commonwealth of Massachusetts � (,% ;: m n . City/Town of . . . System Pumping-Record p'LI;Nu(4f�i 7� Form T V�dm XO[I'P� 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/l �ghtrant of hou�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 City/Town State Zip Code 2. System Owner: Name Address(if different from location) CityfTown • � State jp,�Cade Telephone Number msµ, B. Pumping Record 1. Date of Pumping Date 2 Qu�ntity Pumped: 2-''- Gallons k� ` 3. Type-of system: ❑ Cesspool(s) ElSeptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No, 6. Condition of System: 6. System Pumped By: Nell.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company T. Location whe a contents were disposed: S. Lowell Waste Water Cyrf SlqnAWe 9t Houle Date 06rm4.doc•06/03 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts r'f��r;f City/Town of ` System Pumping Record � Form 4 �rW f � ail I 1tf( 1't �I f / Winl 119 DEP has provided this farm far 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 farm, 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: LeftVLeftl t frontµof house,;Left/Right'rear of house, Left/right side of house, Left/ Right side of building, Right rant of building, Left/Right rear of building, Under deck Address _ C' !Town State Zip Code 2. System Owner: Name Address(if different from location) Citylrown State Telephone Number x ; B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system, ❑ Cesspool(s) © eptickTank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Na If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System, 6. System Pumped By: Nell Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo ti.en- re contents were disposed: a S.M Lowell Waste Water Sign t e Hauie Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 �i- IC6Car 1 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health or oth,Wr approving authority. A. Facility Information 1. System Location: Left side of house Right side of how , Left front f house F i2 ht front of house Le rear of buildi ,Left rear of buildin . Left rear of house, Right rear of house ft g g g Address Cityrrown State Zip Code 2, System Owner: Name Address(if differenk from location) City(rown State Zip Code ___-- Telephone Number B. Pumping Record 1. Date of Pumping ----__..............._ 2. Quantity Pumped: - -..---,...--.._..___ Date Gallons 3. Type of system: Cesspool(s) ®--SeptcTank ❑ Tight Tank ❑ Other(describe): - _.._...._w.___. — .__......_ 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condi ion of Syste 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc_ Company 7. Location where contents were disposed: Waste Water Water Signature of Hauler Date t5form4.doc•06/03 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts n3 City/Town of I :... __. System Pumping Record Form 4 JUN :. 2 20 DEP has provided this form for use by local Boards of Health. Th -pystern Purmpf ng Recon must be submitted to the local Board of Health or other approving auth ritF n y iNr� �. A. Facility Information Important: When filling out 1. Syste Locatia fomes on the � : computer,use only the tab key Address to mare your 4f, - % `W ?• � 1"" cursor-da not k use the return Ci (Town y � State � Zip Code key. 2. System Owner` Name Address nem -------- �.._. — (if different from location) City/Tbwn Stat C"�.�r':.� p1�>C"��"} `Telephone Number .B. Pumping Record 6 1) 1. Date,of Pumpinggate — 2. Quantity Pumped: - - — - Gallons 3. Type of system: [Q Cesspool(s) ( LIptfc Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee'Filter present? ❑ Yes 10 if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: ,. 6. Syste Pumped By Name Vehicle License Number Company .7. Loca ' T where contents wen sposed:, _ Sig tura o a er (nate http://www.mass.gov/dep/wa er/approvals/t5forms.htm#inspect k5form4.doc-06103 System Pumping Record•Page 1 of 1 0h12v0s0b3T Advantage Glaiacn Services RECEIVED 2100 Lakeview Ave . Dracut, MA 01826 L. 1004 TOWN OF NORTH AeN@:)0VER Form of Notice of Casualty Loss to Under Under Mass. Gen. Laws Ch. 1.39 Sec . 3B i N /� l To: Building Commissioner or /Board of Health or Inspector of Buildings Board of Selectmen Town Hall address Town Hall 01.845 North Andover, MA 01845 North Andover, MA Re : Insured: Jay Huapaya Property address : 67 Rock Brook Rd i North Andover, MA 01845 I Policy # : HP2104387 r Loss of : 07/02/04 File or Claim No . AD 7038 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000 . 00 or cause Mass . Gen. Laws, Chapter 143, Section 6 to be applicable . If any notice under Mass Gen_Laws,_Ch._139 Sec 3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title : Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail . 7L Signature and date Commonwealth ormassachusetts Massachusetts $yAtem Puippicig lippord SY.9(Clvl Owner System Location 6 clf� Date of Iltillipilig: 5' -j-D Quahti(y Pumped: gallons Cesspool: No Ves Septic I'm& No I.-] Yes System Pumped by: Felredoet License 11 Cotiteiiis translbrrred to : Greater Lawrerice Sanitary Distric-I Date: Inspector'