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Home My WebLink AboutMiscellaneous - 409 FOREST STREET 4/30/2018 409 FOREST STREET f -2l QtlO6A-00.96-0000.0 I t ' C I f CCommonwealth of Massachusetts REC !'QED City/Town of 03 System Pumping Record NORTH ANDG0V�EtR�HA DQVER Form 4 HEALTH D[PARTMENT 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. A. Facility Information Important: When filling out 1. System Locatio forms on the computer,use only the tab key Address to move your cursor-do not your -V, State Zip Code � ---- ---- use the return Cit o key. --� 2. System Owner: Cl#,l f,6 L�i A Name tC Address(if different from location) --- - ----- City/Town Stat Zip Code is Tele hone-Number B. Pumping Record �/�yy11�, Date 1. Date of Pumping of/o/13— 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): _- 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: i Nam Vehicle License Numb r Company 7. Location where contents were disposed: G•L.S.D. MA— _ 9 Signatu e of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 C Commonwealth of Massachusetts City/Town ofNOMN ECEIVED ANO�oN R System Pumping Record FEB 3 2009 r` Form 4 IJU 4 TOWN OT NORTH ANDOVER 4ti DEP has provided this form for use by local Boards of Health. Other form 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. A. Facility Information Important: When filling out 1. System Location: forms the 409 Fo f e-5 S I computer, r,use l only the tab key Ad re to move your cursor-do not -MA use the return City/Town State Zip Code key. 2. System Owner: VQ Clam K%Y)q Name 1L1 Address(if different from location) Citylrown State Zip Code 9� b�s� -3bi5 Telephone Number B. Pumping Record 1. Date of Pumping I_ a I -OT 2. Quantity Pumped: C3(0 Date Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): / 4. Effluent Tee Filter present? ❑ Yes [1 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Good 6. System Pumped By: Jim Gial l skY4 '7)6? Name Vehicle License Number Ipswich Water Comp ny Treatment Plant 7. Location where contents were disposed: Ipswich, MA 01938 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts R City/Town of NORTH ANDOVER MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The Systern.Pamping Record must be submitted to the local Board of Health or other approving aulhority� � r h '" A. Facility Information MAK 1 0 uub Important: When filling out 1. System Location: TOWN OF NORTH ANDOVER forms on the HEALTH DEPARTMENT computer,use qw� ce-- S` — only the tab key Address to move your cursor-do not A 0- G \N — use the return City/Town State Zip Code key. 2. System Owner: 14 Name — — swc Address(if different from location) City/Town State Zip Code 91 9 29 1G Telephone Number B. Pumping Record 1. Date of Pumping w— p g Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Company--------- 7. ompany --7. Location where contents were disposed: Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Form 4 -- System Pumping Record Commonwealth of Massachusetss - Massachusetts System Pumping Record DEC - 4 2Q02 System Owner System Location �- Ifing Claire Primary dome 409 Fore at 469 rorost North AiWovar, MA. 61845 North Analovor MA. 61845 (978)- 687-4.656 x (978) --687•-4656 v �`ing Cis+r� Type: Emergency Routine Cesspool: No Yes Septic tank: w Yes Date of Pumping: l " ',?- Quantity Pumped: C d Gallons System Pumped By: Wind River Enwronnwtol, LLC Permit#: Contents transferred to: V Contents Disposed at: � r Date: Pumper Signature: 21(Yl Condition of System/Other Comments Dep Approved Form - 12/07/95 Commonwealth of Massachusetts RECEIVED _ City/Town of NORTH ANDOVER q - System Pumping Kecora Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms rrilae "m"it Ulu 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. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use 6 'f �-.only the tab key Address to move our ,/ /� I �) )(� cursor-do not /V• /ll�l O�l7�(_--- ---- ----- `--__�s��_- ---- use the return City/Town State Zip Code key. 2. SystemOwner: 4 <� Namec �r>� An — --- ------- Address(if different from location) ;— — —— City/Town State Zip Code _)?8- 40-ul-s - Telephone Number B. Pumping Record 1. Date of Pumping Date/ j 2. Quantity Pumped: G0O0 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - 4. Effluent Tee Filter present? ❑ Yes [�No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Syste Pump d By: /61 86Q Name Vehicle License Number Company i:pswich Water „� �'e�.tC�tellt Plant 7. Location where contents were disposed: o l psvi4ieh r NAA 61938 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1