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HomeMy WebLinkAboutMiscellaneous - 332 CAMPBELL ROAD 4/30/2018=MWZ� = FORM 4 — SYSTEM PUMPING RECORD Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record System Owner: Rob O'Brien 332 Campbell Road North Andover, MA 01845 Date of Pumping: 11/22/13 Cesspool: No ® Yes ❑ System Location: 332 Campbell Road North Andover 'A'; 0 i 2014 TOWN pF N(.r. n AND HEALTF E� PlAj TMENT Quantity Pumped: 1,250 gallons Septic Tank: No ❑ Yes System Pumped by: D.F. Clark, Inc. License: BHP -2013-0030 Contents transferred to: Ipswich Wastewater Treatment Plant Date: Inspector: Commonwealth of Massachusetts FHEALTH 90 City/Town of 011 W° System Pumping Record Form 4 NDOVER TMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but 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: ouse, right front of house, left side of house, right side of house, Left rear of hou , right rear of house eft side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: a"\,-, Name Address (if different from location) City/Town B. Pumping Record 4-L4-�( 1. Date of Pumping 3. Type of system: ❑ ❑ Oth d b Date Cesspool(s) Telephone Number — 2. Quantity Pumped: ff—S—eptic Tank Gallons ❑ Tight Tank er ( eSCrl e). 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Cond' ion 6)S ys Uk- 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Lo G.L.S. Signature t5form4.doc• 06/03 contents were disposed: n/ell Waste Wator Date 4—(( System Pumping Record • Page 1 of 1 ..irtii•I,L�:���i1ti7i5�.�uj�i..`li,ft•�lkw�wi ��ial� lb• �•yni� tuY.�i� tk J I c.,ri � . � _ _ - _ i �.x1roS .lA/ nlft�•..: , t . tk)t`ii�� it4 i xS 1 l'�4J r- tib~'�'i�ki iy•SW'f�?i i`l ual tui, y�IM-IAr�J 1f1� 1 .. t ;"�. t(kvUq� Pry, M r%.id, �Y 6S , kry.i •,�F H}� a .` SEPSEP 4010 , Commonwealth of Massachusetts . L6NORTH City/Town'of NORTH ANDOVER MAS AN OVER System' Pumping; Record Form 4 DEP has provided this form for use by loyal Boards of Health. The System Pumping Record mu,, be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: Men filling out 1, System Location: _ n fom13 on the computer, use only the tab key to move your cursor •, do not use the return key.,.� 2. T �! 1 1 Cltyrrown Syste er .5 Name 0/051-1 State Zip Code I Address (If different from location) ` %/Town State Zlp Code Telephone Number B. Pumping Record 1. Date of Pumping /D 2. Quantity Pumped: / � p Gallons 3... Type of system:.. ❑ Cesspool(s) XSept1c Tank ❑ Tight Tank Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No I 5. Condition of System: ' s.. S Purgped By: me VehlGe license Number Company 7,1 Locatl where contents were disposed: CGS V/Ml ZIHa er Data htip:#www.mass.gov/depAvater/approvals/t5forms:htm#inspect • '' t5fonn4.doa 08/03 System Pumping Record • Page 1 of i Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rib Commonwealth of Massachusetts City/Town of NORTH ANDOVER,II�IAS ;Aa" E- M System Pumping Record SEP 10 2007 Form 4 T N/N'OF NORTH ANDOVER DEP has provided this form for use by local Boards o l�et:rrTherSyst�enl� ping Record must be submitted to the local Board of Health or other app ving authority. A. Facility Information 1 System Location: 3,-3 2 avv\ 0 belI ` Address ` City/Town 015' State Zip Code 2. System Owner: .QeC� �)'h��� Name Address (if different from location) City/Town Y Stag r� �d -d �2 Telephone Number B. Pumping, Record 1. Date of Pumping 3. Type of system: ❑ h ❑ °Other (describe): <A 2-4 P- 2. Quanti Pum ed: -zoo C -)Date p Gallons Cesspool(s) (Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? Yes ❑ No 1. 5. Condition of System:. 6. System Pumped ay: If yes, was it cleaned? ❑ Yes ❑ No Name Vehicle License Number 1 KO 5S 1 Company V 7. Location where contents were disposed: Uwe �� ICWA Signature of Hauler http://www. mass.gov/dep/water/approvals/t5forms, htm#inspect 2 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 J CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 (978) 774-2772 . FORM 4 - SYSTEM COMMONWEALTH OF MASSACHUSETTS yn , , MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER:," e 33 a cc of p b e SYSTEM LOCATION: 81 ©07 DATE OF PUMPING: 11 9� QUANTITY PUMPED: c CESSPOOL: NO 0 YES F7 SEPTIC TANK: NO SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: // -7 9k INSPECTOR: ml (D 0 -1) -n El -v LC 0 -+, .. Il- ,1., r. .. • • IffVVV/// Tl FTOWN ''FOWN 0 NUK'l tNLX.� v UAI: /�`jSYS'T'ErI1 PUMPINU Rp(-,o '" 7 2005 ©W —9 &AIDR6S5 _ '-_ .__._ .ORTHANDOVER "'"7'r"},`5�EPARTMENT M i.. C '.+ T; c h7 / o. D TI OF pUMP1Nq; QUANTITY PI.rMPEr. NA ruK6 ON s�Rvic:�: xCiv rll(� ub l F -A VA'( (m3. 0,000 MiouiUN NUL-1 ! U truvrak KZAYY 0 38 RGM BXC630IY6 FLOODED CD CA RR YO YAR.."; 01'K R EXPLAIN �'uMM�NTs. AWA ANAbver GZ-A. i+.- )36 A?in St, Ni /fA nD^vs/` WOW lflVa tic k 4 �WIS SJMC TALC 8MWCL;, .nil' MAWMV Mh 01835 978-372-7471 aoco S .. 16 7- /3 Lcirai7��. C'iT i5dd r! a C67el- c e. �I r - A& flap Id . Ce IeI7 �'� loop l�f6 a5 7-t 7a Gins /7-/ 3a� �,,,o ��l �• Ia60 7-/ 166-81160 v�h�5a l add Sad 7'/c. -a -UMrb /e �i 1-ALbo /Q/7e 7- �oov l 14n e �� o ? a3 LcJI t low /?( tact) d /o ( 8rv, /�/� i5ad m TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD ,o HM OWNER & ADDRESS SYSTEM LOCATION (example; left front of house) 3a: U \"I'C OF PUMPINC: QUANTITY PUMPED %dd CALLU�.I NO YES SEPTIC TANK: NO YES '-�TURE OFSERVICE: ROUTINE A EMERGENCY m)I FRV.:\TIONS COOD CONDITION_ FULL TO COVER HFAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK, EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER Oj�HER (EXPLAIN) PUMPCD BY: CU)IMFNTS: Q UN'I L'NTS TIZANSFCIZIZED TO: