HomeMy WebLinkAboutMiscellaneous - 411 SUMMER STREET 4/30/2018 (2) {~ 411 SUMMERSTREET f
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Commonwealth of Massachusetts
RECEIVED
�/ED
_ City/Town of
System Pimping Record �uL 14 2014
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be use , tit 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/Right front of house,Le /Righ of hous 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 Trp Code
2. System Owner.
Name
Address(if different from location)
City/Town ' Stab
C�dip Code
F Cd7d- �.;.
Telephone Number
x i
I
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No:
5. Conditionf stem:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. �Loc�atioerecontents were disposed:
Lowell Waste Water
kD
Sign a Haul Date
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JLa.us Kay M.D., Chairman s 4
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R. George Caron 3 ?�
Edward J. Scanlon MASSACHUSETTS
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Referred to Date Investigated
Result of investigation
Recommendations
Action taken
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EIVED
TOWN OF NOR H ANDOVER OCT 0 5 2004
14�
� SYSTEM PUMp1NQ RECORDUA I'l �12 'AVER
TC \IT
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
91ad
/,
DATE OF PUMPING; _ QUANTITY PUMPED:
(-:0SPOOL: Nu___..... YES,
Septic Tank: NO YES
NA CURE OF SERVICE: ROU'CtNE .._.. __....EMEROENC'1`
c)13SERVA CIONS;
GOOD CONDITION PUL, To COVER
HEAVY OREASE BAFFLES IN PLACE.
ROOTS LBACMELD RUNBACK
BXCE,881VE SOLIDS _ FLOODED
SOLID CARRYOVER, ...�_OTHER EXPLAIN .
Sybtorn Pwnped by
i
COMMENTS,
�'uN t'EN I'3 f'RAN3F'ERREU Lt�
Moe s. "
ANDOVER- MASSACHUSETTS
J �I,..
1$Y e :P,uMj h9.Record
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DEP has provided this form for use by local Boards of Health. The cord ust
be submitted to the local'Board of Health or other approving autho Ity" KL %10
A. Facility information JUN - 4 2007
amgortant:
,r wllerl
'Ung out 1 . System Location TOWN OF NORTH ANDOVER
w:fOr�►u On th0 ' �j� ����y/l E ,LTH DEPARTMENT
CWVUtif use
only the tab key Address
to move your , •'��• �����.����
cur:ardo not Cl
use the return' tY State
t ZJp Code
key 2 System Owner,
t .
Name r
Address(if different from location) , ,
CltyRown State'////^\�/ ZJp Code
Telephone Number
Pumping a ord
•
l � /U C17`
..� Date of Pumpfns ' Date 2. Quantity Pumped: �d
Gallons
3, .`Type of system ❑ Cesspool(s) optic Tank ❑ Tight Tank
10
ther(describe):
4 Effluent Tee Filter present?.❑ Ye No If yes, was if cleaned? ❑ Yes ❑ No
it I
5' ColtditiOn of 8yst?m:'
:_ .+' it Y { l.y{.res.l,la:• Y II�.,
6 Sy e�r1 Pumped By,:
i
Vehicle Ucen
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f' 7. .;Location where contents Were diPposed:
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Slpnature of Hauler,}i u.r. , Dat— a —'
httpJ/www,mass.goV/dept.water/tpp.rQvz ls/tSforms,htm#inspect
t5f6rrn4.doa 003 System Pumping Record .Page t of 1