HomeMy WebLinkAboutMiscellaneous - 11 BRADFORD STREET 4/30/2018 (2) �11 BRADFORD STREET {�
210/061.0-0022-0000.0 `
I
IN
Commonwealth of Massachusetts
City/Town offRE
� D
System Pumping Record
Form 4 SEP 6 2006
DEP has provided this form for use by local Boards of Heal I1.0T1"ystem Pit#"fhb Record must
be submitted to the local Board of'Health or other approvin ate-tbf jfDEPARTId,ENT
X Facility Information
.Important:
When filling out 1. Syste Lo* t,
forms the
computer,
r,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 location)
Cityrrown. State
TelepVoTTe Number
B. Pumping Record
1: Date of Pumping2. Quantity'Pumped:
Date Gallons
.3. Type of system: ❑ Cesspool(s) 9-0 ptic Tank ❑ -right Tank:
Other(describe)
4. Effluent Tee Filter present? ❑ Yes 0. No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of SyMk�
6. System u., eEkBy
Name Vehicle License.Number
Company .
7. Locatio her contenre sed:
W. e
Signa e. H ter Date
hftp://wWw.mass.gov/de ter/approvalt/t5formshtm#inspect
t5form4
.doc• .
06/03
I
System Pum in Record•Pae 1 o
P 9 g f1
Commonwealth of Massachusetts
City/Town of
° System Pumping Record
Form 4
DEP has provided this fbrm 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 house Le Righerear o sLeft/right side of house, Left/
Right side of building, Left/Right front of building, LdMkight rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CilylTown state&A_?- de
Telephone Number
B. Pumping Record
P 9 �.
1. Date of Pumping Date 2. Quantity Pumped: Gallons -T
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'No If yes, was it cleaned? ❑ Yes ❑ No.
5. Condit n f,Sy m•
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License
Number - -
CCEN
E®Bateson Enterprises Inc- R
Company
7. Location where contents were disposed: DEC `ni 3
L Lowell Waste Water TOWN of NORTH ANDOVER
..IY
.L_hffQ0A
Sig Haule Date \J
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECOTHEALI�H
RECEIVED
DATE: SEP - 7 ZOO
5
N ONORTH ANDOJER
DEPARTMEN
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
c �
DATE OF PUMPING: QUANTITY PUMPED 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:
COMMENTS:
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
�(c kct ird �-
1
DATE OF PUMPING: QUANTITY PUMPED l Oub 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: C�/l Z,
COMMENTS:
CONTENTS TRANSFERRED TO: �-
L �
i
FORM 4 - SYSTEM PLALP G oQ
OFNpOF�
®OPS
Commonwealth of Massachusetts
Massachusetts
ystern Pumping Record
SN-stein Owner ester L066fion
Date of Pumping
' �� "� "'"' Quantity Pumped:
Cesspool: No l'es Srntir Tnnl•• Yes
System Pumped by: License #:
Contents transferred to:
Date Inspector
Commonwealth of Massachusetts
h t
Massac uset s
System Pumping Record
System Owner System Location
Date of Pumping: Quantity Pumped: gallons
Cesspool:
Cesspool: No [�]� Yes [] Septic Tank: No [] Yes [---
System Pumped by: 4ZF4" zaavww License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
JAN I I °��
TOWN OF
SYSTEM PUMPING RECORD
3
DATE: O ^ Q 3
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
DATE OF PUMPING: _ - QUANTITY PUMPED : 0—Q 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 RECEIVED,
City/Town of
:,' System Pumping Record DEC 17 2008
Form 4
S�By TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Othems m� se u e
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: Left fro , left rear, ft side fhouse. ight front, right rear, right side of house.
forms on the
computer,use
only the tab key Address
to move your
cursor-do not City/Town State Zi Code
use the return P
k�eY�_____� 2. System Owner:
Name
Address(if different from location)
Cit !Town
Y State
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: 0 Cesspool(s) 0--geptic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? 0 Yes LSO If yes, was it cleaned? 0 Yes 0 No
5. Condition of System:
V,0 , &-k 4�
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationwherp,,contents were disposed:
L.S.D Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
W City/Town of JAN - 3 U11
System Pumping Record TOWN aFNORTH ANDOVER
Form 4 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. ion: Left front of house, right front of house, left side of house, right side of house, U901i ear of ho , right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
6. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? E] Yes 2'90Ifes was it cleaned?
Y ❑ Yes ❑ No
IIT
5. Condition of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. here contents were disposed:
AG ell Wast a
Hau r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1