HomeMy WebLinkAboutMiscellaneous - 174 CANDLESTICK ROAD 4/30/2018 (2)Commonwealth of Massachusetts RECEIVt
City/Town of SEP 2 9 2010
System Pumping Record
TOWN OF NORTH ANDOVER
q,a
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 trt determine the form they use. The System Pumping Record must be submitted to
the local Board of Health motter approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of hous , f ho Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address t �) _
City/Town State Zip Code
2. System Owner: PC)Q 42A(_
Name
Address (if different from location)
City/Town Sta _$R(�eqWXede
Telephone Number
B. Pumping Record
a— (o
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 3 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condjtiorl of System: V\_ ��-
6. System Pumped By:
Neil Bateson F5821
Name
Bateson Enterprises Inc
Company
7. Loc &V contents were disposed:
G. L.S. D
t5form4.doc• 06/03
Vehicle License Number
Date
U
System Pumping Recons . Page 1 of 1
Commonwealth of Massachusetts -
City/Town of F-"' it t —` }'
System Pumping. Record K -OV 0.31014
r Form 4 �
,• TONIN i:.- • : I H ANJWEP. :
DEP has provided this form for use, by local Boards of Health. other forms may be'used, bthe
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 Locatio Righ ont of hous , Left / Right rear of house, Left/ right side of house, Left /
Right side of bui Ing, Left / Right front o building, Left / Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name �J `
Address (d different from location)
CitylTown State � � T.i de .
Telephone Number
B. 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? ❑ Yeas No If yes, was it cleaned? ❑ Yes ❑ No:
5. Condition of s m:
6. System Pumped By:
7.
Neil. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
contents were disposed:
Date
t5fbrm4.doco 06/03 System Pumping Record • Page 1 of 1
�C\- Commonwealth of Massachusetts
City/Town of `p 2 3 13
System Pumping Record
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.
A. Facility Information
1. System Location: Righljront of hous Left/ Right rear of house, Left/ right side of house, Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address [ #7se�'V Ci�F::W)Q
City/Town State Zip Code
2. System Owner.
Name
Aaaress (it aitterent from location)
Citylrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
Telephone Number tf
Date 2. Quantity Pumped: Gallons
Cesspool(s) a eeptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition o� "stem:
� atjjz)�,- \ V1\ QA-o� k -c-
6. System Pumped By:
Neil Bateson
Name
Bateson Entemrises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Date
t5fomt4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
M +
t5form4.doc• 06/03
QCT E 2012
LMEALT-H
OF NORTH ANDavt '
I DEP
AR i MENT
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 Locatio�Ri fr nt of �&Qilding,
Left / Right rear of house, Left / right side of house, Left /
Right side of buil Ing, Left I n Left / Right rear of building, Under deck
CitylTown
2. System Owner.
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State
Zip Code
State � � � Code
Telep one Number
Date 2. Quanb umped: Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes 2' -No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of,S`ystem: l �
v-\-
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Loca ' contents were disposed:
G.L S. Lowell Waste Water
O:t
It
F5821
Vehicle License Number
Date
V -r A
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
a` Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
ISI
�9 � .v... �.� � krE..a. •dF
AUG 13 2008
TOWN OF NORTH ANDOVER
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. SystQm Location: O (;�— vv3u-'�w-.
1 G 4
City/Town
2. System Owner:
Address (if different from location)
City/Town
State
Zip Code
State 6 a c�Z C�
Telephone Number
B. Pumping Record 9-" 9-_62�sl-
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 2'40If yes, was it cleaned? ❑ Yes ❑ No
5. Conditoyste�rm� h
6. Systeme:
Name y4x) Vehicle License Number
Company
7. Location
Signature
s rcont s 7ndisposed:
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: —
a`l CayjesRCL
(example: left front of house)
1 k �o tom- � 6 L),
DATE OF PUMPING: 6- -Q o`�OUANTITY PUMPED--M-(R>- GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE Y EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY: �✓
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: - L - 5 '][�
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. SySte Locatio
forms on the
computer, use
only the tab key Address � �e
tomoveyour
cursor - do not —f
use the return Cityrrown State Zi
key.
2. System Owner:
l
Name
Address (if different from location)
o�c . �P�����
GF
CityfTown SrarA .. G
Telephone Number
.B. Pumping Record
1. Date. of Pumping Date 2. Quantity Pumped.
Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑Tight Tank
❑ Other (describe):
4. Effluent Tee Filter Present? ❑ Yes If yes, was it cleaned? ❑ Yes `❑ No
5. Condition of System: `
0f- AA-'->S-�
�J C
6. SystierUPugipeda BY
�.
Name �--7 Vehicle license Number
v �
Company
.7. Locatio ere conten eres4 osed:.
Signat 0
er Date
TOWN OF &I, t4i.J�
SYSTEM PUMPING RECORD,
DATE: 16 �. '/,
SYSTEM OWNER & ADDRESS
i
n`1 CaVJ C
SYSTEM LOCATION
(example: left front of house)
� j a au5-e
DATE OF PUMPING: 9 ^ O' QUANTITY PUMPED: OCA GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE Y. EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COM NTS:
CONTENTS TRANSFERRED TO:
2
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�I Commonwealth of Massachusetts
/y- , Massachusetts
System Pumping Record
System Owner
R,v,UAO-,r
System Location
Date of Pumping: Quantity Pumped: �� gallons
Cesspool: No t`1" Yes Septic Tank: No [_I Yes V '
System Pumped by: Felredea fi&M,6 as License #
Contents transferrred to : Greater Lawrence Sanitary District
Date:
Inspector:
t
DATE:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
ADDRESS
(example: left front of house)
DATE OF PUMPING: -1 `OL QUANTITY PUMPED
CESSPOOL: NO - YES SEPTIC TANK: NO
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
/EMERGENCY
GALLONS
YES
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: _�--. L •�
P-U13D of HF.�,-, �I
NOTh 4QPOvEl;, MDQ.
ss �e3
APPi�ove-v
DI�PPR�VEp
wAQj6R 5()PFt-I
Lor
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Q fbwn! D UJELL-
5tPTtc SYSTFAcA PE-SI6A3
DArt' z-2� -sem 4PR�OviN6 Aurhol? rY
PLAAJ 00i &Av cc w D T�
D ® SrPr(6 SYSTEM t j SiA u_. Tio"
,�FX4V4Tto, J VjSpt�G6 io,U
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ENn OF L/wE -/G,2aQ ��
. '`.,. •;
'� k
��
t4 ,
TOWN OF
DATE: - I a7 0
SYSTEM OWNER & ADDRESS
6 -(w\ -e( -
n4 cotoA�-S�'C-k
�W&M`16P��,��
I' 6 ' ► 1
R CEIVtD
MAY 2 5 2005
TOWN
TH %Tqa NRgVER
SYSTEM LOCATION
(example: left (front of house)
o- r64-- b �aus-c-
DATE
OF PUMPING: 0 - Q�L QUANTITY PUMPED: ISDO GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
7
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTBER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D V Lowell Waste
Commonwealth of Massachusetts
City/Town ofs�D
System Pumping Record AUG - 6 2007
,•
Form 4
r ,, �, ?N ANDOVER
DEP has provided this form for use by local Boards of Health. Othe�'fbrms Vfi*-' �eVsed4 b _- e
information must be substantially the same as that .provided here. �Beforeng is 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 fitting out 1. Syst LOCat10 L��
forms on the
computer, use
only the tab key Address
to move (�"►r�''� ` C ' " `
cursor - do not
use the return Citylrown State Zip Code
key 2. System Owner: PO
VQ
Name
�m Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State Zip Code
Telephone Number
S�-- 6- -lf--7
Date 2. Quantity Pumped:
C
Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes 9-1q-o-� If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped
Name \ �v \ Vehicl`e License Number
Company
7. Location
content re
�" .
-� 5
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of LRECEIVED
y° System Pumping Record
Form 4 1 1 2009
4�M
Sye�
DEP has provided this form for use by local Boards p&ro§
information must be substantially the same as thatblMu
local Board of Health to determine the form they use. The System Pumpinc
the local Board of Health or other approving authority.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
retro,
be used, but the
this form, check with your
:ord must be submitted to
A. Facility Information
1. System Location eft fron�house, ight front of house, Left rear of house, Right rear of house
Address
City/Town ` State w Zip Code
2. System Owner: P-10 ZVkA-12�
Name
Address (if different from location)
Cityrrown
B. Pumping Record a -Sio�
1 D
ate of Pumping
3. Type of system: ❑
Date
Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ff No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatio re contents were disposed:
L.S.D Lowell Waste Water
Signature of Hauler
State ipjCode
Telephone Number
— 2. Quantity Pumped
eptic Tank
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number F5821
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record SEP 2U'1011
7y SVey`�
Form 4 TOWN OF NORTH ANDOVER
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 Location: Left front of house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
� t7 A)�,V4AIA_
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
State ZipZode
�t ( -QA
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s)Septic Tank
❑ Other (describe):
I �
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition oM�`I
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Loca ' ere contents were disposed:
G. L.S.D. ovV41 Waste at
- \ 111ij —1
Signature
F5821
Vehicle License Number
415? --- 1 :-3 -- l I
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1