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HomeMy WebLinkAboutMiscellaneous - 122 BOXFORD STREET 4/30/2018 (2) / 122 BOXFORD STREET J 2101104.DtWM000.0 / 1,I ti i Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System, Pumping Record Form 4 DEP has provided this form for use by local Boards of HealthFTOUTAIV-tralPling R cord mustbe submitted to the local Board of Health or other approvingty. A. Facility Information LUUU L%WEALTH OF NORTH ANDOVER Important: DEPARTMENT When filling out 1. System Location: forms on the / 0 0 x45 V- computer,use 7 n� /1 1-1 only the tab key Address to move your cursor-do not Cit /Town r'1 I V J a i use the return City/Town Zip Code key. 2 System Owner: - — Name --------- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of PumpingD ce`I © � 2. Quantity Pumped: lions 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 Ped By: IlyName Vehicle License Number Company 7. Locatic � ��disposed: _ VOLD Wll921e1 PIdF'L, _-- - -- MA. Signature of Hauler Date http://www.mass.gov/dep/water/app,rovals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts CitylTown of NORTH ANDOVER MASSA HUS `�T�'�`'D System Pumping Record Form 4 JUN - 5 2006 DEP has provided this form for use by local Boards of Health. Th fy IAMNORTH DOVER mu: be submitted to the local Board of Health or other approving auth i A. Facility Information Important: When filling out I. System Location: forms on the `� 7 computer,use only the tab key ---------- to move your cursor-do not use the return City/Town -- _ -� key. State Zip Code 2. System Owner: � Name NA Address(if different from location) — ---- Stat` 7,0*a Telephone Number `^ B.)Pumping Record 1. Date of Pumping Dat 2. Quantity Pumped: /Ooo 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. Sy em Pump e d JBy: Name L/ _— Vehicle License Number Company �. 7. Location where contents were disposed: ' 1Y _SIiature of Haul Date `7� -- - http.//www,mass.gov/dep/water/ provals/t5forms.htm#inspect e t5€orm4.do -06103 System Pumping Record•Page 1 of 1 � z Form 4 -- System Pumping Record Commonwealth of Massachusetsst t�f`p^OF.1d0j7i-S _ ARD 6F Massachusetts - - System Pumping Record System Owner System location F'.!�:'7rt•rl�r, ,.,rr,+ .M�.'IiL':^r N.Irri,. �' S�['c �++ Ic :Fn F+', 0?8 ,��., ,,,��ic •ry- tL' n7 y.;•; ....r+ •r� naLr•; Type: Emergency Routine Cesspool: No Yes EEI Septic tank: No Yes Er Date of Pumping: Q Quantity Pumped: 'Gallons System Pumped By: Wind River Environmental, LLC Permit#: Contents transferred to: Contents Disposed at: ter Date: Pumper Signature: J Condition of System/Other Comments Dep Approved from - 12/07/95