HomeMy WebLinkAboutMiscellaneous - 16 MARGATE STREET 4/30/2018 (2) a �'
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Commonwealth of Massachusetts
GityfTown of
System Pumping Record NORTH ANDOVER
y
Form 4
ardof Health. Other forms may be used, but the
DEP has provided this form for u localas hatsprovided here. Befo e using his form,check with your
the
information must be substantially Systeme,The Record must be submitted to
local Board of Health to determine the form tau hohey Sity w th n 14 days from the pumping date in
the local Board of Health or other approving
accordance with 31 o CMR 15.351.
A. Facility information
Important:
When filling out 1. System Location:
forms on the -
computer,use - -
P SQL/S'
only the tab key Address ,�'1,�
to move youry /�cyw-7� Zip code
cursor-do not
_ �._..-----.... State
City/Town
use the return
key. 2. System Owner:
Name -
Address(if different from location)
State
— Zip Code
own
cit—yr-r Ilk
Telephone Number
B. Pumping Record
�..------ Z, Quantity Pumped: Gallons
1. Date of Pumping Date_ e
❑
3. Type of system: [�Cesspool(s) ❑ Septic Tank E] 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. RECFIVED
- Vehicle License Number Q
Name "��
��++��,rr.. rp� '�T H ANDOVER
_....--- V.L.-S.D.
Company - TOWN OF NG
rr�� plover, MA. HEALTH DE`?ARTti9ENT
7. Location where contents wN�dtspt7
_..-- -..._. Date
Signature of Hauler
Date
Signature of Receiving Facility
System Pumping Record•Page t of t
t5form4 doc•03106
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSAC U-S- „- WE
k
System -Pumping Record
Form 4 DEC 10 2007
DEP has provided this form for use by local Boards of Health. The B�utpg, ust
be submitted to the local Board of Health or other approving authori y. HEALTH DEPARTMENT
A. Facility Information
Important:
When filling out 1. System Location:
forms on the �(
computer, use u J C,
only the tab key Address
to move your
cursor-do not Cit /Town �
use the return City/Town Zip Code
key.
2. System Owner:
o(t v`nz' L0 h
Name
'I A Address(if different from location)
City/Town State `fZip Code
Telephone Number
B. Pumping
p g Record
OAb7
1. Date of Pumping 2. Quantity Pumped:
Ga ons
3. Type of system: ❑ Cesspool(s) R"Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [�] Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
[Cqek-
6. System Pumped By:
V 631
Name Vehicle License Number
Company
7. Locati n where contents were disposed:
GrClk L�v�r�ce
linfW
-� 07
Signature of u Date
http://www.mass.gov/dep/wa r a ov /t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
Mm City/Town of A �,-W)e(,
0 System Pumping Re
4 •P
Form 4 p g cord
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 Lo tion:
on the computer,
use only the tab /
key to move your Addres -
cursor-do not 14,r --------- --
use the return
key. City/Town
State Zip Code
2. System Own
Name --- -- --_-------�-------.��/��J
Address(if different from location)
-----------------
rcd 0
9 i 2015 -------------_
Cityrrown —-
7tJ' $tate------- ZipCode ---- -
t-.
Telephone Number - -"" - ---------
B. Pumping Record
1. Date of Pumping - 1.2 _�_� 1Y �L�✓V
D — 2. Quantity Pumped:
Gallo :5s --
3. Type of system: Cesspool(') ❑ Septic Tank
❑ Tight Tank ❑ Crease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No —' —
Ifyes, was it cleaned? El Yes ❑ No
5. Condition Of System:
6. System P ped By: -- _- -
Name F -- - - ------- C.� ! �-L�'S
Vehicle License Number -
Company
7. Location where contents were disposed:
Signature of Hauler
Date -"- -----
Signature of Receiving Facility
Date -
t5form4.doc•03/06
System Pumping Record•Page 1 of 1
ti
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS �.
System Pumping Record
o 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 on the 5 n A
computer,use U� � � IG
only the tab key Address v
to move your N, AY-\Ac) �� S d
cursor-do not Cit /Town
use the return y State Zip Code
key.
2. System Owner:
Name �n
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingto C 2. Quantity Pumped: Gal11600
ons
3. Type of system: a/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:
Name Vehicle License Number
Company Ipswich Water 7. Location where contents were disposed: Treatment Plant
geaAe,,- Ipswich, MA01938
Signature of Hauler /a— Date
http://www.mass.gov/dep/water/approt6ls/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
-_ System Pumping Kecora
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.
RE�CEIVED- .
A. Facility Information
FEB - 4 2010
Important:
When filling out 1. System Location:
forms on the g I Mar��� TOWN OF NORTH ANDOVER
computer,use _ _— H DEPARTMFN
only the tab key Address
to move your NoCAln An�oyt,� n_ M�
cursor-do not Cit /Town State Zip Code
use the return City
/Town
2. System Owner:
Name
Address(if different from location) - - - --
City/Town State Zip Code
_9 - --
Telephone Number
B. Pumping Record
1. Date of Pumping Is_09 2. Quantity Pumped: Gallons/000
Date �/
3. Type of system: ❑ Cesspool(s) Ly Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - --
4. Effluent Tee Filter present? ❑ Yes 9 No If yes, was it cleaned? ❑ Yes /No
5. Condition `of System:
Good —. — — --- – --
6. System Pumped By:
_ ,rn Ry'� En v►ronmen&1 ebb-7` _
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
I+
Commonwealth of Massachusetts DEC, 11 101Z
OF NORTH City/Town of lTn)IVNH ANDOVER
16
_ System Pumping Record NORTH ANDOVEREALTHDEIA RTM NT
Form 4
h DEP has provided this form fqr 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
jj -.
computer,use _1
only the tab key Tdrs ®1?q5---
to move your -— - _ .. .. .
cursor-do not City(Town State Zip Code
use the return
key. 2 Syst Owner:
Name
+•^ Address(if diKeren{from Location}
-
State Zip Code
------ -----
Cityrrown
eiephone Number _.
B. Pumping Record
e
1. Date of Pumping pat
-�---- 2. Quantity Pumped: Gallons
'
3. Type of system: ❑ Cesspool(s) c4Septic.Tank ❑ Tight Tank E] Grease Trap
❑ Other(describe): - — _-.---
4. Effluent Tee Filter present? ❑ YesN No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
IMES
---
Name Vehicle License u er
,.
company
7. Location where contents were disposed: G•L•.S.D.
North Andover. M A
ure of Hau Date
---------- --_.
Signature of Receiving Faciiity
15form4.doc•03106 System Pumping Record•Page 1 of 1
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