HomeMy WebLinkAboutMiscellaneous - 160 COLONIAL AVENUE 4/30/2018 160 COLONIAL AVENUE
210/107.13-0105-0000.0
I
�LN Commonwealth of Massachusetts ItECEIVED
u City/Town of NO ANDOVER
UN 10 2013
System Pumping Record
TOWN OF NORTH ANDOVER
Form 4
HE%LTH 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 forms 1. System Location:
on the computer, 1
use only the tab 60 COLONIAL AVE
key to move your Address
cursor-do not NO ANDOVER Ma
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
LATI NA
Name
ienan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingate ( 2. Quantity Pumped: Gall ns
3. Type of system: ❑ Cesspool(s) Septic Tank [ITight Tank ElGrease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condi 'on of Syste(h:
6. Syst ped By:
me Ve cle License Number
Stewart's Septic Service
Company
7. Locati here contents were disposed:
S wart's Pr rtreatment Plant, 20 So. Mill Bradford, Ma 01835
--L--j -
S nature of H ler Date
I na ure o eceiving Facility Date
t5form4.doc•03106 System Pumping Record•Page 1 of 1
5C\ 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 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
computer,use Ao(� cci n.rd n�
only the tab key Address
c ,
to move your � ) , -, �,6
cursor-do not Cityrrown Sta a Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping p g R ecord
v
1. Date of Pumping 2. Quantity�Pum
Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 21io 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:/twww.mass.gov/depAvater/approvals/t5forms.htm#inspect
t5forrn4.doc-06/03 System Pumping Record•Page 1 of 1
. . F,F _ �.1.' •I �'3^�»"dv;s y.�°+r y,�rdrily...r 7 p .Fi.t�7�1a n Rr`3 r
` ;Commonwealth of Massachusetts
x r,
wn of.'NORTH'XANOOVER MASSA
Y L
System Pumping Record
Form
4:
N O V 1. 3 2006
DEP has provided this form for use by local Boards of Health. T e System PumXIn d must
be submitted to the local Board of Health or other approving aut 3p�N OF NORT A
F'{�ALTH DEPARTMENT
k Facility Information .
important:.
- When filling out 1 < System Location:
forms on the
computer,use
only the tab key Address
to move your C-� C� A 14
cursor-do not Cl /Town . State Zip Code
Use the return
key.:.. ; .
2 System Owner
Name
"N Address(if different from location)
City/Town State Zip Code
Telephone Number
6..' Pumping Record
f,
1. Date of Pumping Date - �2. Quantity Pumped: Gallons
3. pe of system: . ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Other(describe):
A. Effluent Tee Filter present?.❑ Yes. l to If yes,was it cleaned? ❑ Yes ❑ No
5 Condition of.System:
6. Sy em Pumped By:
�
Name Vehicle License Number
Company. ..
7. Location where contents were disposed:
a �: ad
Signatur of Hauler . Date
vl
http://www.mass.gov/dep/water/approvali/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
RECEIVED
.41 DOWN OF NOR1' /AANNDnOVf-"P OCT 0 5 2004
`� SYSTEM PUMP1 0 REC'ORI.)
UA CF.. 911�..d.
70ER
HEALTH DEPARTN OF NORTH MENT
NT
SYSTEM OWN ER.& ADDRESS YSTEM LOCATION
CLQ-Z�C�.J •
161d•
t,
DATE OF PI,IMPiN(3:_
�J_Q__.....__..__....�OE.IANTTTY PUMPED:....L _Q .._.
15
CLSSf'WL: NO.___..... YES S00C Tank: NO YES"
NA f URE OFSERVICE; KOU'Ct.NE �Mf-.K UENC)'
U13SE+RVATtONS:
GOOD CONDITION (," FULL'M COVER
HEAVY OREASE BAFFLES IN PLACE
ROOT'S _ LEACHRELD RUNBACK
EXCUSIVE SOLIDS _ FLOODED
SOLID CARRYOVER . _OTHER EXPLAIN
System Pumped by
COMMENTS.
CUN I'EN i'S I'KANSFI~RUD f() C��)4
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
�1'STEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
Aa L9
OF PUMPING, 911'1,21QUANTITY PUMPED CALLO'�')
( I'�.SI'OOL: NO ✓ YES SEPTIC TANK: NO YES —
NATURE OF SERVICE: ROUTINE ✓ EMERGENCY
(mSERV.;\TIONS:
GOOD CONDI'T'ION V FULL TO COVER
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER �4�HER (EXPLAIN)
>1' 'I'LM PUMPED BY: // 1 1 6-
cu11IYIENTS:
�:UNTENTr TIZANSFEIZRED TO: