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Home My WebLink AboutMiscellaneous - 107 LIBERTY STREET 4/30/2018 (2) 7e-7 CN Commonwealth of Massachusetts City/Town of NORTH ANDOVER VI-1 System Pumping Record Form 4 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 forms 1. System Location: on the computer, use only the tab 107 LIBERTY STREET key to move your Address cursor-do not NORTH ANDOVER MA 01845 use the return City/Town State Zip Code key. 2. System Owner: LUIS CARRILLO Name mnm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 11/03/14 2. Quantity Pumped: 1500 Date Gallons 3. Component: ❑ 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. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II H79 406 Name Vehicle License Number X SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD 11/03/14 Sign re of Hauler - Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts w City/Town of NORTH ANDOVER W° System Pumping Record j Form 4 '�M 5eya 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 RECEIVED Important:When filling out forms 1. System Location: NOV 2Q�J on the computer, use only the tab 107 LIBERTY STREET key to move your Address TOWN OF Nt..-r 'r:nNUU t cursor-do not NORTH ANDOVER MA H15AIl DEP.ARTME _ . 5 use the return City/Town State Zip Code key. 2. System Owner: LUIS CARRILLO Name ream Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 10/30/13 2. Quantity Pumped: 1500 Gallons 3. Component: ❑ 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. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II H79 406 Name Vehicle License Number S SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD y: . LL 10/30/13 Signatur fla I r Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of NO. ANDOVER System Pumping Record `cam Form 4 �M 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. -- 91, Cal 13 A. Facility Information Important: nee -bd 011 When filling out 1. System Location: forms on the TOWN OF NORTH ANDOVER 107 LIBERTY ST. computer,use H only the tab key Address to move your NO.ANDOVER MA 01845 cursor-do not City/Town State Zip Code use the return key 2. System Owner: rQ LUIS CARILLO Name feA� Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 11/9/11 2. Quantity Pumped: 1500 Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Lid No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By.- James y:James H. Currier H79 406 Name Vehicle License Number J's Septic&Drain Company 7. Location where contents were disposed: GLSD - 11/9/11 Signature of Hauler Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 i FNOVI EIVE® -C-\ Commonwealth of Massachusetts City/Town of NO. ANDOVER 2 2012 System Pum in Record TOWN OF NORTH ANDOVER p g HEALTH DEPARTMENT Form 4 �M 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 Location: forms on the computer,use 107 LIBERTY ST. only the tab key Address to move your NO.ANDOVER MA 01845 cursor-do not use the return City/Town State Zip Code key. 2. System Owner: r� LUIS CARRILO Name ieuen Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 10/22/12 2. Quantity Pumped: 1500 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. CURRIER H79 406 Name Vehicle License Number J's SEPTIC&DRAIN Company 7. Location where contents were disposed: GLSD 10/22/12 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record-Page 1 of 1 C\ Commonwealth of Massachusetts RBCBI City/Town of NO. ANDOVER DEC -J ZU10 System Pumping Record TOWN OF NORTH ANDOVER Form 4 L 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 Important: When filling out 1. System Location: forms on the computer,use 107 LIBERTY ST. only the tab key Address to move your NO. ANDOVER MA 01845 cursor-do not City/Town State Zi Code use the return p key. 2. System Owner: t LUIS CARRILLO Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 11/16/10 uaPumped: 1500 2• ntity Pd: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ 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. Currier H79 406 Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD 4L�— �� -77 11/16/10 Sig ure of Hauler Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 .C-\ Commonwealth of Massachusetts RECEIVED City/Town ofNow" A*%C0NWr4Eoos FEBEEB 3 ° System Pumping Record Form 4 T�HEA�H 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 Location: forms the �� t ��.l cC � computer,use t� D only the tab key Address to move your cursor-do not City/Tow•own State Zip Code use the return key. 2. System Owner: Name F2�T-J&l Address(if different from location) City/Town State Zip Code 9-73- e9S- ba-�F Telephone Number B. Pumping Record 1. Date of Pumping I20`0 2. Quantity Pumped: Date Gallons 3. Type of system: El Cesspool(s) VSeptic 06 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: Oft 6. System Pumped By: Na� Vehicle License Number Company 7. Location where contents were disposed: Ipswich Water Treatment-, Plant Signa re of Hauler pswic MAat®1933 Signature of Receiving Facility Date t5form4.doc•03106 System Pumping Record•Page 1 of 1 _ Commonwealth of Massachusetts Fy City/Town of NORTH ANDOVER, MASSACHUSETTS ( System Pumping Record Form 4 DEP has provided this form for use by local Boards of HealtRecord must be submitted to the local Board of Health or other approving auth VE A. Facility Information NOV 13 2006 Important: When filling out 1. System Location: TOWN OF NORTH ANDOVER forms on the HEALTH DEPARTMENT i/�� computer,use LJ-7 only the tab key Addres pp _f`�� to move your ./Ufiy'17'� 4n66 �Y V( cursor-do not use the return City/Town State Zip Code key. 2. Syst m Owner. A0 Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping - / 2. Quantity Pumped: 1 Date ,�/ Gallons 3. Type of system: ❑ Cesspool(s) LJ Septic Tank ❑ Tight Tank ❑ Other(describe): ---- 4. Effluent Tee Filter present? ❑ Yes M No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: _ Name Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Date http://www.mass.govldep/water/approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ENV! RON MENTAL IN 4.z}YS sit PUlap) ;1iEC4RD SEPTIC& S2RVl .E 107 FPR-ryT S_M,.cT;lvMtLe•GN,ry A 0t949 • - L'L�"`vyyv�Vl�'!1�:i1-•�v i'i�"\."ls�f f1.<<ClI�IIEA I.l•.. " 1,u2a0 V C �. scac s S pjvAiG k C'O)U) SYSTENt oWNF.P_ SYSTEM L0C A..70N: y Clv Zack- �0 7 4 /0 e,—le A ! 10� N- tzrc7- IQ-r5 f s t d e j Al" f Lsc c4r- DATE OF Plp,,Jp•TNG: QliKItiT?a Y PvNr3. 1 S UCS —GALLONS CESSP()QL: NO YDS 71 SPTIC T,42NK_: NO YES SYS Myj PUNAPcD SAY: CONTENTS TRANSFPR Z-D TG: 6� L S➢ DATE' RU 1� y�r7�'r:1:71U '�IQIQI� :.f_ ''=._ :.]•_.�[�'�,.._--r •IW'I ';{_ i?m�:.'1+JH; i.6�4. �lNd�+dS u.0t1-1 Td Wt5 l:LN 000E T 1 '1:,0 yEt?u�SL8�6 i 'Qi l :�,ti.� HShI'1aH1 i0d� dl>iJbdS i i0��