HomeMy WebLinkAboutMiscellaneous - 99 HAY MEADOW ROAD 4/30/2018Commonwealth of Massachusetts RECEIVED
City/Town of JUN 15 2015
System Pumping. Record
Form 4 TOKEN OF NORTH ANDOVER
WA'I„TR IUARTMENT
DEP has provided this form for usezby 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/ Right front of house, Left/ Right rear of house, Left t'.�-ide of houssu Left /
Right side of building, Left / Right front of building, Left / Right rear of building,U�e--� c cf
Address
Cityrrown v� State Zip Code
2. System Owner.
Name
Address (if different from location)
City/Town S
Telephone Number
B. Pumping
1. Date of Pumping
rd
Date 2• Q antity Pumped
3. Type -of system: ❑ Cesspool(s) Septic Tank
o
Gallons ,
❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yeas E21No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditionof Sy$teC Civ l lam,
6. System Pumped By.-
Neil.
y:
Neil. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. Loca ' re contents were disposed:
/a L S. Lowell Waste Water
(j,
Date
t5form4.doo- 06/03 System Pumping Record • Page 1 of 1
9
I\- -_
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
f' 2013
TOWN Or NORTH ANDOVER
HEALTH DEPF.!?TMENT
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 front of house, right front of house, left side of house, ' i e of hous ; Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:��-
Name '_ l
Address (if different from location)
City/Town State G E— � Z, i l e a
Telephone Number l�
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: s�
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditin of Sys I'il:
6. System Pum y:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
G.L. . D. Lowe as Water
Signa re of f,auler
t5form4.doc• 06/03
F5821
Vehicle License Number
Date
-81-13
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts ti
City/Town of"C VE
System Pumping Record
Form 4 N0,14 z-010
DEP has provided this form for use by local Boards of Health. Other fir d9I119Y
information must be substantially the same as that provided here. Be ,,,� ith 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 front of house, right front of house, left side of hou ri ht side of hous$P, Left
rear of house, right rear of house, left side of building, right rear of building, under c.
dec
qq e
-e� 4400-Q�—
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
Cityl-rown
Telephone Number
B. Pumping Record
1. Date of Pumping Date �eptic
Pumped:
3. Type of system: ❑ Cesspool(s) k
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ED- o
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
5. Condition ofSystem: tLJJJ-- ) A
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Loca�re contents were disposed:
L. S. D.
Sigwurtof/iauler
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
�-L—\ Commonwealth of Massachusetts
City/Town of RECEI�/ ® v
System Pumping Record
g
Form 4 JUN 16 2008
DEP has provided this form for use by local Boards of Health. Othe fbi `I s:F RTH A �v4ffh
I'l1� .
information must be substantially the same as that provided here. B 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
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address q ^
to move your �-9l t—
cursor - do not City/Town State
use the return
key. 2. System Owner:
Name
ISI Address (if different from location)
Citylrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Iwo,.
0 • %a
Zip Code
State/a-7� Lf
Telephone Number
2. Quantity Pumped: Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Q ,r
6. System Pumped ��gy:
Name icle License Number
Company
7. Location re content were
Date
t5form4.doc- 06/03 System Pumping Record . Page 1 of 1
I
SYSTEM PUMPING RECORD
DATE: t(— (-01(
SYSTEM OWNER & ADDRESS
DATE OF PUMPING:
SYSTEM LOCATION
(example: left front of house)
U
1
QUANTITY PUMPED:
RECEIVED
NOV - 9 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
CESSPOOL: NO SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTIIER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED To: G.L.S.D Lowell Waste
GALLONS
TOWN OF P"
SYSTEM PIMPING RECORD
DATE:
W",
�� g 2003
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
hb b
h
DATE OF PUMPING: ? 3 QUANTITY PUMPED:
l GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
-x �'nn1t1 nw1=�111111f M�s�t1c44uselt�
ass cl se s
• 11 11 IlmnizaL
PRIP of I'ulltping: tk--- 9 r9e---
L'esspuc�l: No 1 "Y Yes L)
System vocalior►
3
Qtlaillily Nulllped: �5�� gallons
Septic Tack: No U Yes L�
SY01e111 I'1tt11ped by: iR,1i"04,04 5K&OWW-4 License #
collisills I141181boned 1t1 t giloat@[ iAMIJIGN monitory ulmulat
I -ate: _ Inspector:
System Owner
k,do
Comm weal of Massachusetts
/Ij Massachusetts
System Pumping Record
Date of Pumping:r c
Cesspool: No [,]� Yes [ ]
System Pumped by: V4&"tit
System Location
qf at HteeAi4_.,1
Quantity Pumped: /_,� gallons
Septic Tank: No [ ]
License #
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
Yes rr_�
1
yowx AdA/�-
FOUNT 4 - SYSTFNt PL1tPL\G KECOIW
Conunon«vealth of Alassachuse(ts
, Massachusetts
,'vstern IN", -)M9 Record
ystem Location
Date of Pumping L 0 Quantity Pumped: t C
Cesspool: No `T Yes El 'SPn1ir Tan T��� �] YesP.-� J vz�
System Pumped by: License #:
Contents transferred to: - L --
Date
Inspector
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