HomeMy WebLinkAboutMiscellaneous - 2200 TURNPIKE STREET 4/30/2018 (2)Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER
I lo System Pumping Record
;M 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. Rrt',, }_
A. Facility Information
Important: When
filling out forms 1.
System Location:
on the computer,
use only the tab
2200 TURNPIKE STREET
key to move your
Address
cursor - do not
NORTH ANDOVER
use the return
City/Town
key.
2. System Owner:
LARRY TRACEY
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Component:
❑ Other (describe)
12/2/14
Eig GC2014
TOWN Ut- NUK i h ANUUVER
HEALTH DEPA6 NIENT
MA
State
State
Telephone Number
2 Q tit P d'
01845
Zip Code
Zip Code
1000
Date Uan I y Umpe . Gallons
❑ Cesspool(s) ® Septic Tank ❑ Tight Tank 0._ Grease Trap
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER II
Name
X SEPTIC & DRAIN
Company
7. Location where
GLSD Z
Signature of Hauler
were disposed:
If yes, was it cleaned? ❑ Yes ❑ No
H79 406
Vehicle License Number
12/2/2014
Date
Signature of Receiving Facility (or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1
,C\ Commonwealth of !Massachusetts
= City/Tpwn of NO. ANDOVER
System Pumping Record
Dorm 4
'M
Important:
When filling out
forms on the
computer, u_se
only the tab key
to move your
cursor - do not
use the return
key.
tG3
t5form4.doc• 06/03
MAR 0 6 2007
{ TOWN OF NORTH ANDOVER
l HEALTH DEPARTMENT
l�
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:
2200 TURNPIKE ST.
NO.ANDOVER MA
City/Town state
2. System Owner.:
LARRY TRACEY
Address (if different from location)
City/rown
B. Pumping Record
1. Date of Pumping 2/12/07Date
3. Type of system: ElCesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes R No
5. Condition of System:
6. System Pumped By:
Benjamin Shute
Name
J's Septic & Drain
Company
7, Location where contents were disposed:
GLSD
Hauler
State
Telephone Number
01845
Zip Code
Zip Code
— 2. Quantity Pumped: 1000
Gallons
Septic Tank ❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
H79 406
Vehicle License Number
2/12/0 7
Date
System Pumping Record • Page 1 of 1
I
CUIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
SYSTEM OWNER:
FORM 4 - SYSTEM PUMPING RECORD
t TOWN OF NORTH ANDn`�
BOARD OF HEAD':-;
tC tI
1 �8111 1
i N
COMMONWEALTH OF MASSACHUSETTS
,A/,A4/01a MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM LOCATION:
OL41AC16 C/
DATE OF PUMPING: I r`-�. QUANTITY PUMPED: GG G GALLONS
CESSPOOL: NO 0 YES E:] SEPTIC TANK: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE:
INSPECTOR:
Commonweaun oj tvlu�Juc:«u�GL"
Massachusetts h
�System .�mp>!ME Record DRi
Bcaner
system ocation
J jv�`-
Type: Emergency 0 Routine D'�
�—,/ Yes El Septic Tank: No F] Yes
Cesspool: No LTJ
Date of Pumping: J o1� /a Quantity .Pumped:, ^ 1 � G o gallons
' � a �,,�, • �:
System Pumped by (CompanyPermit). .
Contents transferred to:
.Contents disposed at:
=GSi
Date Pumper Signature
Condition of system/other comments:
DEP APPROVED FORM - L-JO719S
e
TOWN OF _ N • Avi Jn ilei
SYSTEM PUMPING RECORD
DATE: + IS -6 I
SYSTEM OWNER & ADDRESS
co t' hvl_�
dao l -T��f 1, L'c Sf
Ot- 1mv..0 E��t e r
SYSTEM LOCATION
(example: left front of house) --
DATE OF PUMPING: - O I q QUANTITY PUMPED: 15Q6 GAL ONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE 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.
COMMENTS:
CONTENTS TRANSFERRED TO:
G.L.S.D
Lowell Waste
FORM 4 - SYSTEM PUMPING RECORD
zwea kh of Mass"huseus
Massachusetts
/4&(7 I2xcy
AA
Type: Emergency ❑.
Cesspool: No Yes ❑
Date of Pumping: _ - U y
Routine N
OCT 0 6 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Septic Tank: No ❑ Yes
Quantity Pumped: /V o 0 gallons
System Pumped by (Company): YPermit #:
Contents transferred to:
Contents disposed at:
Date Pumper Signature
Condition of system/other comments: _
ECEI`d'ED
Commonwealth of Massachusetts
City/Town of NO. ANDOVER 2913
System Pumping Record
Form 4
'M svBv`e
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.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
remm
A. Facility Information
1. System Location:
2200 TURNPIKE ST.
Address
NO.ANDOVER
City/Town
2. System Owner:
LAWRENCE TRACY
Name
Address (if different from location)
City/Town
MA
State
State
Telephone Number
B. Pumping Record
1. Date of Pumping 12/3/12 2. Quantity Pumped:
Date
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ® No
5. Condition of System:
6. System Pumped By:
JAMES H. CURRIER
Name
J's SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
Signature,,wiladierr��
Signature of Receiving Facility
01845
Zip Code
Zip Code
1000
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
H79 406
Vehicle License Number
12/3/12
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1