HomeMy WebLinkAboutMiscellaneous - 1000 JOHNSON STREET 4/30/2018Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record JUIN
Form 4
Towti P.# 4 s tki VG3k
DEP has provided this form for use by local Boards of Health. Other Lfonbii�a i!be usedMaja
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 a Righ ear of hous. Left /right side of house, Left /
Right side of building, Left / Right front of building, Left / Rig rear of building, Under deck
Address
QWTown state
2. System Owner.
Name
Zp Code
Address rd different from location)
Citylrown � State � de .
Telephone Number
i
B Pumping Record�f
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned?
❑ Yes ❑ No;
5. Condition of 011, : J`� �oj „ Q \ .� C'��
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatign4ioere contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
—C
Date
t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
RECEIVED
JUN 2 4 2013
TOWN OF NORTH ANDOVER
HEALTH 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.
A. Facility Information
1. System Location: Left / Right front of hous Left g rear of house eft / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
Cityrrown State
2. System Owner.
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
Zip Code
Stateo—Z* Code
Telephone Number
Date 2.
Quantity Pumped
Cesspool(s) Septic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f System:
. POS \-�--
6. System Pumped By:
Neil Bateson
Name
Bateson Entemrises Inc
Company
7. Location !!�ere contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
&—
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts�'� =°'=
City/Town of
System Pumping Record SEP 14 200
FOrm 4 TOWN OF NORTH ANDOVER
HEALTH DE,3A'R1, ENT
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 authority. .
A. Facility Information
1. System Lo!atiox —
Address
City/Town Statei
2_ System Owner.
Name
City/Town
Zip Code
State Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity' Pumped
I Type of system: ❑ Cesspool(s) ptic Tank
El Other (describe):
Ga ons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes" ❑ No
5: Condition of System:
6. System P mp dc8y:�
Name rA n,_
Company
7. Location w contents 7we di ed
http://www.mass.
htm#inspect
Vehicle License Number
Date
t5form4.doc• 06103 System Pumping Record • Page 1 of 1
TOWN OF
SYSTEM PUMPING RECO
DATE:
SYSTEM OWNER & ADDRESS
DATE OF PUMPING:
EIVED
SEP 16 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM LOCATION
(example: left front of house)
QUANTITY PUMPED:
CESSPOOL: NO v YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
GALLONS
I
t ,
i
Culu11u1Na1N11�1 br �IAs1�IrbUselU
E�Tp4,,�y 0 •I J,OVER/
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U
Important:
When filling out
fomes on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key
_Q
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
RECEIVED
JUN 2 5 2007
TOWN OF NORTH ANDOVER
HEALTH DEFARTMENI
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:
Address
Cityrrown
2. System Owner:
Name
Address (if different from
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
Other (describe):
State
�rac�
— 2. Quantity Pumped
Septic Tank
Zip Code
StateZj Code
Telephone Number
Date
Cesspool(s)
C�
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes I -No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition IS tc'�7-0k
A
System Pr
Name \ ^ Vehicle License Number
v
Company
7. Location
t5form4.doc• 06/03
§1
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
RECEIVE
City/Town of
System Pumping Record SEP 2 7 2007
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Ot T W M Z
information must be substantially the same as that provided here. Before using this form, check th your
local Board of Health to determine the form they use. The System Pumping Record must be sub itted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. Syste Location:
forms on the
computer, use
only the tab key Address E � _ACL
to move your
cursor - do not City/Town State 0�1Zip Code
use the return
key. 2. System Owner: tr/ C
II
Soc/(
Name
y Address (if different from location)
Cityrrown State Zip Code
��� e�3
Telephone Number
B. Pumping Record
1. Date of Pumping bate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
)n '!�:) T
'IC/tJ
6. System P m .By:
Name LVehicle License Number
Company
7. Location
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
V
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
&I
ISI
RECEV w—D
SEP 0 8 2008
TOWN OF NORTH ANDOVER
HEALTH DEPAR T NiENT
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 Locatio :
t`P '(
Address <1`
City/Town State
2. System Owner.
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Zip Code
State/` � �,--pp-Code
Telephone Number
2-- D -7--C� /. C -
Date 2. Quantity Pumped: Gallons
Cesspool(s) eptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes Q -Ivo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of SV-Aystem: �� tv�-a I
&I 4Z7�-�
6. System Pumped By:
Name��� q�=_�'"`"� J � Vide License Number
P . C.:
Company
7. Location ere contents vw
Date
t5form4.doc^ 06/03 System Pumping Record . Page 1 of 1
N Commonwealth of Massachusetts
City/Town of MVED
System Pumping RecordAUG 10 2010
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other fo s Ip
information must be substantially the same as that provided here. Before using tnis torm, 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 ouottxer approving authority.
A. Facility Information
1. System Location: -Left side of house, Right side of house, Left front of house, Right front of house,
r_TiTrea� ous fight rear 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
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
cl-1 q—
State Zip Code
Telephone Number
9-4—rD
2_ Quantity Pumped:
�pticTank
Date
Cesspool(s)
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes Leo If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiop of Syste(et_'em: ,,k \
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. LocafierrwhereLcontents were disposed:
G.L.
F5821
Vehicle License Number
Date
t5form4.doc• 06/03
System Pumping Recons •Page 1 of 1
Commonwealth of Massachusetts
City/Town of
RECEIVE
a System Pumping Record
Form 4 SEP 12 1011
�M
DEP has provided this form for use by local Board' 4" �I ay be used, but the
ISSinformation must be substantially the same as tha g 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 house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
(C"o koc-�VN
Cityrrown State Zip Code
2. System Owner:
Name
Address (if different from location)
Cityrrown
B. Pumping Record 2--13
1. Date of Pumping
3. Type of system
Date
❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
5. Condit'o, n pf System:
6. System Pumped By:
Neil J. Bateson
7.
State�.� ,, Zip Code
Telephone Number
— 2. Quantity Pumped
eptic Tank
C�
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
Sig
L.S.D.
contents were disposed:
— R--,3 (- � C
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1