HomeMy WebLinkAboutMiscellaneous - 242 LACY STREET 4/30/2018 (2)Commonwealth of Massachusetts 7RECEIIVED
City/Town ofSystem Pumping Record2014
Form 4
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DEP has provided this form for use; by local Boards of Health. Other few s may a 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 i h# front of Nous eft /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
AddressQL
Citylrown State
2. System Owner.
Name
Address (If different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system. ❑
4.
Date
Zip Code
�GZip Code
(p
Telephone Number
2. Quantity Pumped:
Cesspool(s) eptic Tank
Gallons
❑ Tight Tank
❑ Other (describe):
Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned?
5. Condition of S}j C'AgC �CZ_�
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location re, contents were disposed:
Lowell Waste Wz
F5821
Vehicle License Number
Date
❑ Yes ❑ No,
t5form4.doa- 06/03 System Pumping Record ° Page 1 of 1
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Commonwealth of Massachusetts
City/Town of REC�I\I'E®
System Pumping Record
Form 4 APR 2 3 2008
DEP has provided this form for use by local Boards of Health. Oth
information must be substantially the same as that provided here. -thisf k 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:
C� k"� �---
Address ! S�T-— AA <
Citylrown State Zip Code
2. System Owner:
Name
Address (if different from location)
City/ Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Statef ^ ,,,,Zip Code
Telephone Number
Date 2. Quantity Pumped: Gallons
Cesspool(s)Q--Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes Q -No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition
\ System -
VV -
6. Syste n - 7:
Name sv Vehicle License Number
Company
7. Locatio here contents Isposed:
L� S. -
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
TOWN OF NORTH ANDOVER« ; ; --
SYSTEM PUMPING RECORD'
OCT 2 4 2005
DATE. TOWN OF NO Z -H ANDOVER
HEA' :L '�T
SS
DATE OF PUMPING:
CESSPOOL: NO YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
(example: left front of house)
PUMPED GALLONS
SEPTIC TANK: NO
EMERGENCY
YES
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO:
Connnonwealtl► of Massachusetts
IVO (A P Ik-rMassachusetts
System Pumping Record
System Owner
Date of Pumping: cSA3/ q 7
Cesspool: NoA/ Yes LI
System Location
Itrz, IOvcy -�
/1)6(--h �IIJOVC✓
Quairiity Pumped: 10 d 0 gallons
Septic Tank: No Yes
System Pumped by: vdrejea ore&,�fta ,d License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Yl / q� Inspector:
NORTH V "JOS, _../
.nARO OF 6-9�.'oi.; 4
31999 l
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: _o I
1a
2-q 7- La(I
SYSTEM LOCATION
(example: left front of house)
r�Ik+ ��f 0I` f�a.se
DATE OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE YIEMERGENCY
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: 6.2— - , b
� Commonwealth of Massachusetts RECEIVED
City/Town of DEC 1 5 2009
System Pumping Record
Form 4 T�HEA�LTH DEPA T ENTF NORTH ER
wM
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 tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health of -other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of hou e,�ing.
Left rear of house, Right rear of house. Left rear of building. Right rear of buil
Addressl j a , �
City/Town
D-
�/1 1. I`-^/�Jli J State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
State Zi Code
I --0c) -'�
Telephone Number
B. Pumping Record
la--�--
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 [�Io If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location w ere contents were disposed:
L.S.D Lowell Waste Water
Signature of Hauler
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts RECEIVE --D"""
City/Town of OCT 20 2012
System Pumping Record TOWN OF NORTH ANDOVER
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 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 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 7si-- /(U- ,(
City/Town State
2. System Owner:
Name
Address (if different from location)
HCA'-,�C-�Q �--u
Zip Code
City/Town Stat S— �Zode
) —(
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date 2. Quantity Pumped.
Cesspool(s)Septic Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes (moo If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi o System: �4� -0� l V-\-
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location w contents were disposed:
GL S. _ Lowell Waste Water
t5form4.doc• 06/03
F5821
Vehicle License Number
Date
System Pumping Recons • Page 1 of 1