HomeMy WebLinkAboutMiscellaneous - 221 CAMPBELL ROAD 4/30/2018 (3) got. A
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: Commonwealth of Massachusetts
City/Town of .
RECEIVED
System Pumping.Record MAY 2 7 2015
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.
PP 9 .
A. Facility. Information
1. System Location: Left ' li#front of Nous Left/Right rear of
Y g house, Left/right side of house, Left/
Right side of building, Left/Rig t front of building, Left/Right rear of building, Under deck
Address
Ctiyrrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown Stag _&qgtCode
i
Telephone Number i
B. Pumping Record
��Qs
1. Date of Pumping Date 2. Quantity Pumped: Gallons }
3. Type of system: ❑ Cesspool(s) �, emetic Tank
LA'S p ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 3<0 If yes,was it cleaned? ❑ Yes ❑ No
5. Condition o I; stem:
6: System Pumped By.-
Nell.
y:Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. 7Lo where contents-were disposed:
L S'. Lowell Waste Water
Sign HaulleiU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RE ,�
City/Town of
System Pumping Record t" 2 2013
+ FOrftll 4 TOWNOF
MD RRRT DOVER
I DEP has provided this form for use by local Boards of Health. Other forms may be useMx e
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.
j A. Facility Information
1. System Location: Left i front of house, 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
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City(rown State Zip Code
Telephone Number
B. Pumping Record
--�3 3
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? ❑ Yes D-90 If yes, was it cleaned? ❑ Yes ❑ No:
5. Condi ion of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ' where contents were disposed:
GLL S. Lowell Waste Water
Sign t e Haule Date .
t5fom4.doc•06103 System Pumping Record•Page 1 of 1
i
I
�L\ Commonwealth of Massachusetts RECEIVED
City/Town of
~ System Pumping Record APR 1U12
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: Le ht front of ho , Left/Right rear of house Left/right side of house Left/
9 � ,
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
I
Address(if different from location)
I
City/Town State "Code i
Telephone Number �L
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) El-8 Ic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Conditi n of System:
luoc�� J%o-,uj,L v\ 4 MA J�
6. System Pumped By:
Neil Bateson F5821.
Name Vehicle License Number
Bateson Enterprises Inc
Company
e
7. Location where contents were disposed:
.L S. Lowell Waste Water `
a ����
9sige Haule Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
Commonweal
� th of Massachusetts
City/Town of RECEIVED
System Pumping Record l4-
Form 4 k �
V
TOWN OF NORTH ANDOVIM
DEP has provided this form for use-by local Boards of Health. Other fo s iiia jRbiitthe
information must be substantial the same as that provided here. Before—using�.�..
IY p .thls 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
nformation
1. System Location: Left Q Eight front of hous Left/Right near of house, Left/right side of house, Left/
Right side of building, Left/Right fronto uildirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(d different from location)
CitylTown state/')v Ge#e ,
Telephone Number
B. Pumping Record
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 No Ifes, was it cleaned? Yes N
Y a
i
' 5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
Sig Haul Date
I
i
I
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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