HomeMy WebLinkAboutMiscellaneous - 1070 SALEM STREET 4/30/2018 (3) 1070 SALEM STREET
210/106.A-0046-0000.0 `
1
;t?
Commonwealth of Massachusetts I
City/Town of RECEIVED
System PWmping-Record JUL 16 ?o15
Form 4
TOWN OF NORTH ANDOVER
EA H DEPARIYMENT
DEP has provided this form •
for usevby local Boards of Health. Otter orms 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 Nous , L /Righ of hous eft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig t rear of building, Under deck
Address 10 v �c%CJ"�'tJ�1J S' PO4'�
City/Town State Zip Code
2. System Owner.
\0
Name'
Address(d different from location)
CitylTown State � ;
r"5
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: canons
. I
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0_14�0 If yes,was it cleaned? ❑ Yes ❑ No,
5. Conditi n of System:UA � V
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. 7Lo— ere contents,were disposed:
Lowell Waste Water
Si n Haul
9 Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
C\- Commonwealth of Massachusetts RECEIVED N;�
City/Town of ' I
a DEC 15 2009
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
wM HEALTH DEPARTNIFENT
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 side of house, Right side of house, Left front of house, Right front of house,
61`17r-e�ar of ous', Right rear of house. Left rear of building. Right rear of building.
A
Addre
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State _ j0--i.,41-13 1pode
Telepumber
B. Pumping Record ]
1. Date of Pumping 2. Quantity Pumped: C/fes
Datteo 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: V
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio contents were disposed:
L
LAS.D zi Lowell Waste Water
qgrpture of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth.of Massachusetts
City/Town of
System Pumping Record
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 authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms the
computer,use
only the tab key Address
to move your
cursor-do not
use the return Cityrrown State Zip Code
key.
2. System Owner
Name
Address(if different from:locationJ
Cityfrown. State Zip Code
Telephone Number
B. PurnR' ` j
Record
n9 . .
1: .Date.of Pum ringDate 2- Quantity`Pumped:
Gallons
.3. Type of system ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑
Other(descrlbe) .
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yet:❑ No
6. Condition of s sfem:
V V
6. Syste PUP
P��d BY
Name.
Vehicle License Number
Company l l
7. Location re ontent re di sed::
Signatu of ui Date
http://www.mass.gov/depfwat r/a rovals/t5forms1-Ittn#inspect
t5form4.doc•06103
System Pumping Record•Page 1 of 1
Commonweal( i of Massachusetts
&"-A
�. assachusctts
System Pumping Record
System Owner System Location
0V7n
Date of Pumping; Quantity Pumped: h gallons
Cesspool: No Yes L_) Septic Tank: No Yes
System Pumped by: FCtreoda 514,f f tied License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: __ Inspector-
Z,ay O
s, nHA
/
Fr +01'
- i
o.
_------- —
•
----------� q�ii�71•� ftil'>�1N� i��I�►1�� :,tq Ir�rf+iiri,l �uolii��
___.�:,) sa el ( � +►N :�++u 1. ��iriag I i ��•, � ++t�l pin+irro��
�qn psi rarb+in�l ,tilNi�+r�i �� `e�� Q� :H+ilii+iiii,l 1+i
CX-0) TT
1�1
Ilei ip��y Ili�it� Isom�y iiiolrY �
p���e�
---6L r = - ---- - -- - - -- -
Y
m
--- — ---- - ---- --- --— A-11-ne __;
x --1
_ _ � - � ��
{ I�i�1.
� . _� �^
' r_..__._...._._._ _. ____._�____ ..A_ ,. _. __�._ r
._ - - -- -- ;- - -- - ----- -- --y.-- - ------- - .. T -.._. _ -------...-- --._.._
_.. _ .. ..-- - .. ------._ ---- ---- - -- -- - --- ---- ..-t------- - - --
t
f '
.�
y
r-
� �1
._-____.__-_---__-_ ._...__V..______.
% S
_. _._ _ _ _ _ ._-.--_ ._ _. __ .�. .._. �-___-�T.�___- ____ -_-._._.____.___-._.-_�. _. -
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
.ev
a1(- ��
- .
Date of Pumping: , ;-= _._ Quantity.Pumped: CJ. gallons
Cesspool: No Yes ❑ Septic Tank: No ❑ Yes
S
m
System Pumped b : 6Q��4�r ` ° License# Y
Y P Y . . .
Contents transferrred to Greeter Lawrence Sanitary District r
Date: E: Inspector;
FORM 4- SYSTEM Pt1iPD;G RECORD
IR/
gQA
Commonwealth of Massachusetts
Massachusetts , 1
System Pumping Record
}stem Owner Systern Location
EV
Date of Pumping: v7 Quantity Pumped: (5?-�- gallons
Cesspool: No Yes ❑ Septic Tank: No ❑ Yes
System Pumped by- _ License #:
Contents transferred to:
Date Inspector
I
Conunomv alth of Massachusetts
v�C' Massachusetts
stem Pumping Record
System Owner System Location
1
Date of Pumping. (luahtity Pumped. �`� gallons
Cesspool: No Yes U Septic Tank: No ❑ Yes L
System Pumped by: Farejea Sit&#t taa License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Inspector:
1
TOWN OF0
NORTH ANDOVER CT
SYSTEM PUMPING RECORD ! �5 ZOps
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
coavuWCW
DATE OF PUMPING: 10—q-o( QUANTITY PUMPED 1 15e6 GALLONS
CESSPOOL: NO YYES SEPTIC TANK: NO YES
—Z
NATURE OF SERVICE: ROUTINE ZEMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: ___(�F 'L /L
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: "
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
6UT
to-To
DATE OF PUMPING: QUANTITY PUMPED-t<a-�> GALLONS
CESSPOOL: NO ZYES SEPTIC TANK: -NO YES
I
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
I
CONTENTS TRANSFERRED TO: _�'
TOWN OF
SYSTEM PUMPING RECORD,,.,� _,
gra
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
co
to
-10
DATE OF PUMPING: -o3 QUANTITY PUMPED : GALLON
CESSPOOL: NO YES PTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLA 4)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CoNTENTs TRANsFERRED To: G.L.S.D Lowell Waste
TOWN OF
SYSTEM P ING RECORD RECEIVE®
DATE: b NOV 19 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
0J,c,w .
DATE OF PUMPING: QUANTITY PUMPED: 150D GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS.TRANSFERRED TO: G.L.S.D Lowell Waste
Commonwealth of Massachusetts
City/Town of RECEIVE®
System Pumping Record DEC 17 2008
Form 4
- TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other for s mAN—HU MAT T
information must be substantially the same as that provided here. Before using this form, check with your
local Board of HealthAo 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: Left fron le re , left si of o se Right front, right rear, right side of house.
forms on the
computer,use
only the tab key Address 70
to move your
cursor-do not City/Town State Zip Code
use the return
key. 2 System Owner:
Name
Address(if different from location)
Cityfrown State " de
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qua tity Pumped: Gallons
3. Type of system: Cesspool(s) _ Septic Tank [] Tight Tank
p Other(describe):
4. Effluent Tee Filter present? Yes If yes, was it cleaned? Yes [] No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio where contents were disposed:
I
r. Lowell Waste Water
L � ��
r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts LVED
City/Town of M 20 2012
a
�
m Pumping Syste p ng Record
TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for us&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,/Right ear �f hf h ,us-4, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
ttno
Cityrrown State Zip Code
2. System Owner. ` S
Name '
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �2Qu ntityumpe
Pd:
Date Gallons
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L No 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. Location where contents were disposed:
L S. Lowell Waste Water
Cr �c9 � r�
Sign t e IHaul. Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
