HomeMy WebLinkAboutMiscellaneous - 23 SULLIVAN STREET 4/30/2018 23 SULLIVAN STREET
210/107.B-0098-0000.0
Claims Processing - Arnica Scan Center Toll Free: 1-888-70-AMICA
PO Box 9690 (1-888-702-6422)
o Providence, RI 02940-9690 Fax: 1-888-999-5821 f
AUTO HOME LIFE {
September 15, 2015
Town of North Andover
120 Main Street
North Andover, MA 01845
i
File Number: 60002254314
Date of Loss: 09/14/2015
Owner/ Insured: Timothy P. Jacques
Street: 23 Sullivan Street
Town: North Andover
Type of Loss: Water
To Whom This May Concern:
Please be advised that we insure the above named individual(s). A claim has been made
for Damage to Real Property and as the insurer, we are presently in the process of adjusting the
loss.
We are mandated to comply with Massachusetts General Laws, Chapter 139 and as such,
if there are any present liens on the above property, please notify us within 10 days of receipt of
this letter. If we do not hear from you, we will be under no obligation to pay you any portion
of this claim.
Sincerely,
e�OT
Eric H. Meister CPCU, AIC
Claims Department
888-702-6422 x21105
EMEISTER@AMICA.COM
Commonwealth of Massachusetts
CIty/TQM of NORTH ANDOVER MASSA ;r
D
- System Pumping Record -�
-.. Form 4 SSP - 6 2006
DEP has provided this form for use by local Boards of Health. NVASiys-R1gbP9 rA vJBj RLV rd mu;
be submitted to the local Board of Health or other approving auk orf LTH Q�,ENT
A. Facility Information
Important:
When filling out 1. System Location:
forms the
computer, use
only the tab key Address - � —--- '----to move your -
cursor-do not � U'_
use the return City/Town State .---.
State ----------- ---......
key. Zip Code
2. System Owner:
Name ----
j� ,p -
Addreu(if different from location) -------
City/Town '-------- --_- - -_ State----- ---- -- -
Telephone Number
B. Pumping Record
1. Date of Pumping
p g Dace _ _ 2. Quantity Pumped: -_.----.___. -..
Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
El Other(describe): ----_— .... �_._ ..._ ...-- - -- ----- —. . -- --- ------
4. Effluent Tee Filter present? ❑ Yes . If yes, was it cleaned? ❑ Yes o
'
5. Condition of System:
6. kePumped By:
Vehicle License Number --
Company VtCI `/
7. Location where contents were disposed:
Si ature of Hai - ------ _.__
Dale
http://www.masg;gov/dep/water/ provals/t5forms.htm#inspect
t5form4.doc,06/03
System Pumping Record - Page 1 of
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Commonwealth of MassachusettsFTOWN
E�V I�
City/Town of NORTH ANDOVER MUS&TS
System Pumping Record
QrH
Form 4
mEPA�1rINt
MWVM
DEP has provided this form for use by local Boards of Health. The System Pumping Record
Y p must
be submitted to the local Board of Health or other approving authority. g
_A..Facility Information
Important
When filling out 1. Sy, m Locatio
forms on the I i
computer,use Ades, 1/
only the tab key �� _ I C�V•�i�
to move your
curuse the
return
of City/Town State
use the return Zip Code,
key.., 2. System^Owner.
Name
j
Address(If different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping W/0 Da 2. Quantity Pumped: /
Gallons
j 3. I Type of system: . . ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If ye§,*avas it cleaned? ❑ Yes ❑ No
S. Condition of System:
6. Syste Pu ped By
Na VehlGa License Number
D V
IG
Company
7. Location where con ants ere disposed:
Aq
XSlgnaturef Hauler Da
http://www.mass.gov/depAvater/approvalslt5forms.htm#inspect •'`'
t5form4.doc•06/03 °r n.• System Pumping Record•Page 1 of 1
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