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HomeMy WebLinkAboutMiscellaneous - 83 ACADEMY ROAD 4/30/2018 (3)L\ Commonwealth of Massachusetts City/Town of System pumping Record NORTH ANDOVER Form 4 Boards Of Hearth. Other forms may be used. but the L)EP has provided this form for use by local Boa sing this form, ct%eckwith Your is that provided here - Before u information must be substantially the sOM0 I pumping Record must be submitted -Jo I Board of Health to determine the form they use. The System focal days from- the pumping date in the local Board of Health or other approving authority within 14 accordance' with 310 CMR 15,351. AIR Facility information Important., Men Tilting out System Location' fofMS on the. computer, use only the tabuey Address I SYS to move your Zip Coe cursor - do not L State cilyfrawn use the reluir, key. 7 System owner: . ame Address S(� f iflerent frOM loca ion) ate Z-ip Cod ctyrTown 92t? B. pumping Record 2, Quantity Pumped' Galt" 1. Date Of Pumping Date 3 Type of System. ❑cesspool($) n-jL--'pfic Tank ❑ Tight Tank ❑ Grease Trap ❑ other, (ciescribe)', 4. Efffuent Tee . Filter present? C] Yes ❑ No 5. Condition of System: 6: System Pumped By: —4� Nam ---Leellt Company 7. Location where contents were disposed: Signature of Hauler Tjqrj.Wur—e o—jke-eeIVTn-g Facility jsIorm4.doc-031.05 if yes. was it cleaned? M Yes [1 No Vehicle License -Number 14 bite, 0% System Pvcnptng.RetWO P290 I of i Invortot: v\rhen filling out forms an the GQMPIA91, use -only The tab key to Move,you? cursor - do net use the return key. Commonwealth of Massac,-h usetts City/Town of System pumping Record iNORTH ANDOVER Form 4 rds of Health.. Other forms may be used, but the DEP has provided this form for .use by local 130a check vAth You( Information must be substantially the same as that provided here. EWore using this form, local Board of Health to deterrnine the form they -use. The Syslem pumping Record must be SubMitted to the local Board Of Health or otherapproving authority within 14 days from the pumping date in accordance With 310 CMR 15.351. A. Facility information j. System, Location, kf)� 4diress cilyrravon Z. system Owner., Norm Address tif.ditferent from tocaltonj iea'I'e Zip Code Stale ZIP cod 92,9 Ti6jM_0M Number B. Ptimping Record 2. Quantity Pumped' "tam 1, Date of pumping Date 3. Type Of sYstsystem:Cl CCesspools)n-!§;;p_tic Tank ❑ Tight Tank C] Grease Trap 0 Other (describe)-. 4. Effluent Tee Filter present? E3 yes LI No if yes. was it cleaned? 'M Yes O'No 5. Condition.ol"System: 6; System Pumped BY: 0 vetilWe License Number Name company. 7. Location where contents were disposed: IA - of Receiving Facilit—Y Te t5fom'4.doC- OY06 0 Date System pt -ping _Pewd - P39e I 'Of I Commonwealth of Massachusetts City/Town of _ System Pumping Record NORTH ANDOVER Form 4 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 ust be submitted to the local Board of Health or other approving authority withi 14 spin date in accordance with 310 CMR 15.351. 6. System Pumped By: Gn-- — —9 ----- - - Name Vehicle License Number Eng1c0nmtn10A Company 7. Location where contents were disposed: r,A _------ Signature of Hauler 1 Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 - A. Facility Information `•" v � bV 11 TOWN OF NORTH ANDOVER Important: When filling out 1. System Location: HEALTH DEPARTMENT forms on the computer, use zj bAC�� ---------------._...___.--- only the tab key to move your — -- Address \^ U�� `1 1 -� MA I_ S cursor - do notCity(rown — — --- — ----- — -- State Zip Code use the return key. 2 System Owner: Name Address different from location) (if - - -- — --- ---- City[Town State Zip Code - as — ---- - Telephone Number B. Pumping Record - I b_ o — - ----- 1. Date of Pumping Date 2. Quantity Pumped: Gallons / 3. Type of system: F]Cesspool(s) LVA 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: "I- I5Arm ©ce f'rjiNwlci (� p ��YiS�. - ---- ---- — ----- - — 6. System Pumped By: Gn-- — —9 ----- - - Name Vehicle License Number Eng1c0nmtn10A Company 7. Location where contents were disposed: r,A _------ Signature of Hauler 1 Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health be submitted to the local Board of Health or other approving A. Facility Information 1. System Location: Addres 6 Q� IAC .— City/Town 2. System Owner: C� 0 dne`U. S�e�en 5 Name V Address (if different rom to tion) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: h ❑ Other (describe): State JUN 0 4 2008 ord must DEPARTMENT Zip Code State22 Zip Code Telephone Number Date 2. Quantity Pumped Cesspool(s) ❑ Septic Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: _ SW Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By: �e CAR 0 Name Vehicle License Number Company --- 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 Commonwealth of Mossachusetss : Massachusetts System Pumoina Record .-•,cn 111 rr i� athv :7`:'JP,Nu 7-O 71H Al L rJER 'i. O1 d'i '.001 1 '3' ?8 ' 11-1 Type: Emergency Routine Cesspool: No Yes Date of Pumping: �7G System Pumped By: Wind Rives Environmental, UC Contents transferred to: Location 8 3 < < Alit �fil !"VII hJR•.: I A14Dk-'M' . MA u * 15 Contents Disposed at. (S-L_S') 1 ()122s) Date: of System/Other Comments Pumper Signature: Dep Approved Fran► - 12/07/95 Form 4 -- System Pumping Record 4441 302001 Septic tank: No Yes E� Quantity Pumped: r ^ Gallons Permit 7t: Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSE System -Pumping Record �l. Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. (rab DEP has provided this form for use by local Boards of Health. be submitted to the local Board of Health or other approving A. Facility Information 1, System Location: 83 ACCc� Address City/Town 2. System Owner: _ S-tcv��s' C Name Address (if different from location) City/Town B. Pumping Record ^ Date —G� 2. Quantity Pumped ❑ Cesspool(s) ❑ Septic Tank AUG - 7 2007 TOWN OF NORTH ANDOVER HEALTH DEP'ARTik'ENT State Zip Code State Zip Code Telephone Number 1. Date of Pumping 3. Type of system: ❑ Other (describe) 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: _� �%r��o`► _ Name Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Company 7. Location where contents were disposed: _0 sQ 4 __ Signature of Ha r Date http://www.mass.gov/dep/water/ prov /t5forms.htm#inspect rd must t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 r 022201672C) System Owner Steven:j Corn*41ia Or Kathy 83 Acddemy Rd forth Andover, MA, 01815 (978)-b83-5522 x Type: Emergen Cesspool: No Date of Pumping_ System Pumped By: Contents Transferred to: Contents Disposed at: Commonwealth of Massachusetts Massachusetts System Pumping Record Routine Yes Wind River Environmental, LLC WOW= Form 4 -- System Pumping Record RECE E.0 AUG - 7 2001 TOWN OF NORTH ANDOVER System Location Primary Home 83 Ac ,ide_my Rd Noith Andover, KA, 01845 (y78) -b83 -5h22 Stevens Date: _! � d 7 Pumper Signature: t/�/` Condition of System/Other Comments Dep Approved Form - 12/07/95 Septic Tank: No = Yes Quantity Pumped: j�On Gallons Permit #: Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts RECEIVED City/Town of NOM A*1NC)WjE System Pumping Record MAY 0 6 2009 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms m ly be used- , -,Mrrrvu 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 1. System Location: A3Acc.8e City/Town 2. System Owner: S+e- s Cocvcl��, Name Address ,,(if different from location) /�c�trk� �v�Cdtre� CitylTown MAL— aft%& State Zip Code /Ai14 C)i°Qj State Zip Code e7?�— G433's J22 Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date 3. Type of system: ❑ Cesspool(s) [/]Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes E?' -No 5. Condition of System: 0,00 G lonsOv ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By: f I- V'�r 'A98'Q Name Vehicle License Number Comp ny w1bONEW4 7. Location where contents were disposed: Ipswich Water Signature of Hauler I reatment Plant Inc" A 16C Signature of Receivi i s MA 01938 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 �-L\ Commonwealth of Massachusetts VED City/Town of NORTH ANDOVER _ System Pumping Kecora 14 Z00 LHEALTH Form 4 ORTH ANDOVER *" DEPARTMENT DEP has provided this form for use by local Boards of Health. Other f 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 Pu, Ing Record must be submitted to the local Board of Health or other approving authority within 14 days fro the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms on the 1. System Location: �• /�� use— computer, only the tab key to move your Address `� Nov vh I" `An6ovc( _____ _ Q --- o o� q 5' - cursor - do not use the return City/Town State Zip Code key. 2. System Owner: f CV C'n S - — -- — Name — different from location) –- Address (if City/Town State Zip Code q -?,R saa Telephone Number B. Pumping Record 1. Date of Pumping IC) - b -09 2. Quantity Pumped: 1 S00 p g Date Gallons 500GO 1 i 00a &L 1 3. Type of system: d Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [dNo 5. Condition of System: 6. System Pumped By: 3yyl GQ11 Qy) Name wi,('� 1' -ye-t �nvi�o men�a� Company 7. Location where contents were disposed: G.L.S.D. _ Signature of Hauler LaWrence, MA. Signature of Receiving Facility If yes, was it cleaned? ❑ Yes [j No 7bb-1 Vehicle License Number Date Date l5form4.doc• 03/06 System Pumping Record • Page 1 of 1