HomeMy WebLinkAboutMiscellaneous - 1025 FOREST STREET 4/30/2018 (2)# r
i
,�Z_\ Commonwealth of Massachusetts
City/Town of North Andover
_ — a System Pumping Record
Form 4
'wy cal Boards of Health. Other forms may be used, but the
DEP has provided this form for use by long this form, with your
information must be substantially the Sam e as that provided here. Before usiReco d must be submitted to
local Board of Health to determine the form they use. The System Pumping date in
the local Board of Health or other approving authority within 14 days from the pumping,
accordance with 310 CMR 15.351. 4 4
A. Facility information
important When
filling out forms 1. System Location:
on the computer, 1,(-)a
�, �—
use only the tab
key to move your Address 01886
cursor - do not North Andover Ma
State Zip Code
use the return CityfTown
key.
2. System Owner:
4 Name
ramp
Address (if different from location)
State Zip Code
City/Town
Telephone Number
B. Pumping Record
'
1. Date of Pumping Pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If.yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ^_ O
6. tem Pumped By:
Vehicle License Number
Name
Stewart's Septic ervice
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
of Hauler
Signature of Receiving Facility
Date
Date
System Pumping Record • Page 1 c
Commonwealth of Massachusetts
W City/Town of No andover
System Pumping Record NOV 12 2013
^M Form 4 �o�::, UOVER
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.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
rah
A. Facility Information
1. System Location:
1025 Forest ST
Address
No Andover Ma
CityfTown State Zip Code
2. System Owner:
-D onato
Name
Address (if different from location)
City/Town
State
Telephone Number
B. Pumping Record
1. Date of Pumping ate ✓ 2. Quantity Pumped
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
Septic Tank ❑ Tight Tank
Zip Code
G lob! ns
❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S em:
6. System Pumped B
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Ste art's re -treatment Plant, 20 So. Mill Bradford
S
r
Vehicle License Number
Ma 01835
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of, NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
r` Form 4
'M
DEP has provided this form for use by local Boards of Health. The System PumpingR _ econ
be submitted to the local Board of Health or other approving auth
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Iml
A. Facility Information
1. System Location:
Address -0 O G G 4
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State
CA
JUL 1 9 2006
TOWN ur- rvUK i H ANDOVER I
HEALTH DEPARTMENT
Zip Code
Stat Zip Code
�5F�r/-13cy
Telephone Number
Glgl'06 2. Quantity Pumped
Date
Cesspools) goeptic Tank
4. Effluent Tee Filter present? ❑ Yes o
5. Cond'tion of System:
Ao,vv S�/d( 4-
IlonU s )
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
6. System Pumped By:
�,'r f j 7-, S3 3 S �-
Name VehicleLicenseNumber
Company �--�
7. Location where contents were disposed:
as k
ignature of ler Date
http://www.mass.gov/dep/wat approvals/t5forms.htm#inspect
1,
must
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
77
& ADDRESS
bybl-EM LOCATION
-front of house)
7-73
-X- Al,
lltvj-i� - i�,:, e , i'�,4 , )p
----------------------
"QUANTITY PUMPED GALLONS
OL: No YES SEPTIC TANK: NO
YES
t. TURE OF SERVIC
E; ROUTINE
EMERGENCY
x TIONS:
A
.-#,-wv
" GOOD '
WNDITION
FULL TO COVER
HEAVY GREASE
BAFFLES IN PLACE
ROOTS
E s LEACHyIELD RUNBACK
EXCESSIVE SIVE SOLIDS FLOODED
SOLIDS CARRYOVER
OTHER (EXPLAIN)
aHh F
c�Toi�
4t
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
77
& ADDRESS
bybl-EM LOCATION
-front of house)
7-73
-X- Al,
lltvj-i� - i�,:, e , i'�,4 , )p
----------------------
"QUANTITY PUMPED GALLONS
OL: No YES SEPTIC TANK: NO
YES
t. TURE OF SERVIC
E; ROUTINE
EMERGENCY
x TIONS:
A
.-#,-wv
" GOOD '
WNDITION
FULL TO COVER
HEAVY GREASE
BAFFLES IN PLACE
ROOTS
E s LEACHyIELD RUNBACK
EXCESSIVE SIVE SOLIDS FLOODED
SOLIDS CARRYOVER
OTHER (EXPLAIN)
aHh F
c�Toi�
i
• t
M OF NORT'AiiDOVER
SYSTEM PUM'PINC RECORD
uwr�E;R & ADDRESS
SYSTEM LOC'AT Orr
Icfl from of ,
uI C UFVPUMP(NC, QUANTITY ('UMf'CD�
;':CUVD"C.VN01I'l0N NULL TO CUYr IZ•
FIEA`•YY'C:K:ASC' ' ` BAFFLES IN I)I,ACI' — -
RU.OTS. LEACHFICLD 1ZUNr3AC'K. ^----
CXCESSI`YE SOLIDS FLOODED
PUM('C0Y;:
U01. M f,, NTS
1
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WN NO
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DEP,.has prdWded thla form for use by local Boards of Health. The System P
be submitted to the.local'Board of Health or other approving authors
A:. Facility lnforoption .
;�ungo►tan ,: :: •,i:
�Whel, filun9 out • :1:. System .Uo tlon
OVER
.,,A
p gNT Record must
SJ-
z'u'/.
S� ., Zip Code
rarM
StateZI Code
Telephone Number �~ 32/
,.: P.umping:Retio d;
ij1!.Ii.!'�q�•i;••
Da of Pumpl
n�' ,Dat 2. Quantity Pumped:
', •. G Ions
3,: ':Type Qf
system,.... ❑ Cesspool($) (J�Ieptic Tank ❑ Tight Tank
Other (describe)
4 Effluent Tee Filter
resent?. ❑ Yes i o If yes, was It cleaned? ❑Yes ❑ No
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���: httpJ/r�nvw,mass.gov/deplrvaWA PprGva)s/t5forms,htm#Inspect
• � t5form4.doa! OdIQ3 � .
;•y; System PUMPing Record Page 1 or {
Of
oNy the tab key Address
to move your
wr:or • do Dot
:�'• ;; ;��i i'; !
; System Ow, ner•'..:'
NaJTIe':.'r:`';,;
Address (if different from location)
OVER
.,,A
p gNT Record must
SJ-
z'u'/.
S� ., Zip Code
rarM
StateZI Code
Telephone Number �~ 32/
,.: P.umping:Retio d;
ij1!.Ii.!'�q�•i;••
Da of Pumpl
n�' ,Dat 2. Quantity Pumped:
', •. G Ions
3,: ':Type Qf
system,.... ❑ Cesspool($) (J�Ieptic Tank ❑ Tight Tank
Other (describe)
4 Effluent Tee Filter
resent?. ❑ Yes i o If yes, was It cleaned? ❑Yes ❑ No
' ',9%'• .7i1'•;Y^i,?t rp; j'q:rt:•:h+.jT. !l'�� l'. Jt"1.1'`;�'''••'�' � � .
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. �•�., ' ;-;:.� : '•.`r.':�i"J.�• .,..i '... �,;:" . ....., vans
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• ':'•>:p,f.J'r:i:,' , �.,1 •r. ; 't. .� �,,1�"(���r�1V.i 4 w•,.
7;' Locatlon.where'contents wera':dl;3posed.
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31
:,•,.;: '. ;:,>~..,; of
nstur '.Slpauler;i
�..: ;,=r.:•,1-3.:fv-+..r �.r, :•::.. e Date
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• � t5form4.doa! OdIQ3 � .
;•y; System PUMPing Record Page 1 or {
v*
'rowN OF NORTH ANDOVER
L) A 1'k 541 SYSTEM i PUMPINQ RECOIL)
\ I/
iYSTEM OWNER & ADDRESS
-Z)!9e,4-77)
ln�)& 1Qra-,s-7L (37
x/,/). Ad44e�
DATE OF PUMPING:
byb[ � LOCATION
_QUANTITY PUMPED:
CESSPOOL: NO-VYFs
... ... ZSOP(ic Tank: NU
NArURE OF SERVICE: R0U-rINk...v-'-'EmER(JbN(,).
NOV - 3 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
YES l/—
vESERVA [IONS:
Es4----
013SERVATIONS:
000D CONDITION/ -""FU
HEAVY OREkSE LL'N COVER
ROOTS BAFFLES IN PLACE.
LEACKRE-LD RUNBACK
BXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER_..'.
"-- OTKER EXPLAIN
..
systom Pwnpcd by Lso
177a.
�:UMMENTS.
CUN I EN I'Zi f'KAN3FhKUL) J�c)
I
2
t1v
system u%%mer
DAVID DONATO
Commonwealth of Massachusetts
N. ANDOVER . Massachusetts
,System Pumning Record
REC `. ,
SEP 15 2 8 - 1025 FORREST STREET
TOWN OF NORTH ,.
HEALTH dG'k, "
Date of Pumping: 8/4I8 Quantity Pumped: 1000 gallons
Cesspool: No Yes . ❑ Septic Tank: No ❑ Yes
RAGGS SEPTIC SERVICE, INC. _
System Pumped by: d.b.a. E . A. COMEAU SEPTIC License :
Contents transferred to: _ FITCHBURG TREATMENT PLANT _ _
Date 8/4/08 ' Inspector RAGGS SEPTIC SERVICE, INC .
f r'• ''C1i F'f'�j%�f14jlY�l.Vi'w1'n. +.r CtrNJt(w rL i { ¢t , +f :. �",.7,c ,
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V
i
Commonwealth !of MassachuseNORThIANt OVM
;.city/Town.'of•,NORTH ANDOVE TS
System' Pumping: Record k ,
Form' 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record n
be submitted to the local Board of Health or other approving authority.
Facility Information
ng out 1, System Location:
the
key A
,o ,our :.
'pmt City/Town state
Zip Code
2, System Owner
1
Name
Address (If different from locatlon)
k,
Mr—town State Zlp Code
Telephone Number
B. Pumping Record
1, Date of Pumping 1 gate / 2. Quantity Pumped:
Gallons
3..., Type of system: ❑ Cesspool(s) Septic Tank ❑Tight Tank
Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If ye`s`'avas It cleaned? []'Yes ❑ No
5. Condition of System:
CIS -
6. Bye Vehicle License Number 1
Company " � e-
7, . Locatlo where contents were disposed:
dkmLJ)ck
1
o � �
S gnature of Hauler . Date
mass.govldep/water/approvais/t5forms.htm#Inspect • k j
1 .
08/03 ^ System Pumping Reoord • Page t of i
ILN Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSAC MR -b
, I\V
System Pumping Record
Form 4 JAN 0 0 20.10
DEP has provided this form for use by local Boards of Health. TheWw"Ptiiffiv �gl must
be submitted to the local Board of Health or other approving autho HEALTH DEPARTMENT
A. Facility Information
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
ISI
F --M
1. System Location:
102-5
Address
City/Town
2. System Owner:
J>Ay % Ul
Name
Address (if different from location)
City/Town
LvLp<
State
State
Telephone Number
t E3 1--i -
Zip Code
Zip Code
B. Pumping Record
1. Date of PumpingDate 3 , 2. Quantity Pumped: Gallons a
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 9-lqo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
At V-( God -G•. , 37-9 I U
Name Vehicle License Number
Z� P > l Siryit e n C•
Comp
7. Location where contents were disposed:
Ci/3 /Zc�e,- _
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc• 06103 System Pumping Record • Page 1 of