HomeMy WebLinkAboutMiscellaneous - 49 ABBOTT STREET 8/25/2015 i
Commonwealth of Massachusetts
City/Town oi
= d
X91
Form 4 q s iV r, r
®EP has provided this form for use�by local Boards of Hea i. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your I
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 fight side of house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, n er eck
Address
State
City/Town Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown State Zip Code
Telephone Number ti
B. Pumping Record
1. Cate of Pumping ate � 2. Quantity Pumped:
Date Gallons
3. Type of system: Cesspool(s) ptic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yap o�mM If yes, was it cleaned? Yes No,
5. Condition of stern:
6; System Pumped By:
Neil Bateson F5821
Name vehicle License Number
Bateson Enterprises Inc
Gompany
7. Location w re contents-were disposed:
L S. " Lowell Waste Water
Sign WHaule
Gate
t5form4.doc^06/03 System Pumping Record a Page 1 of 1
1
Commonwealth of Massachusetts
C ity/Town of L!") ?O E
System Pumping Record
Y � �
Form 4 uf 1f. 6i� P1 l�„
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/Right front of house, Left/Right rear of house, Left/ side of hous , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address / Cr `�
CitylTown —�"" State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown ' State' C ip o
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic 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:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ere contents were disposed:
S. Lowell Waste Water
SignAtufe I Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record RECEIVED"
Form 4"
" � 2 0
DEP has provided this form for use by local Boards of Health. Other orms may be used, but the
information must be substantially the same as that provided here. B o ttsin i�g"fdrffi'[ ith your
local Board of Health to determine the form they use. The System P "" � � 9 itted to
the local Board of Health or other approving authority.
A. Facility Information
Important: °"—"
When filling out 1. System Location: Left front, left rear, left side of housgoni ht fr `aright rear, right side of house.
forms on the r�
computer,use ` b
only the tab key Address
to move your
cursor-do not Cityffowna State Zip Code
use the return
key. 2. System Owner:
V?" N's Y
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped: Gallons �
3. Type of system: 0 Cesspool(s) deptic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? 0 Yes K/No If yes,was it cleaned? E] Yes [ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S. Lowell Waste Water
7
igna ure of H Or Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
k II
Commonwealth. of Massachusetts
City/Town of
System Pumping Record
Form 4
i N
f
iGyM 4'y`'Y �4 p„EI
' ®A
DEP has provided this form for use by local Boards=of Health. The Syst6'Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
�°w � .,
When filling out 1. System Location:
forms on the
computer,use
only the tab key Addres
to move your
cursor-do not
use thei return CityfTown tate Zip Code
key.
2. System OWner:
Name
fCtr"' Address(if different from location)
Cityfrown Sta .
Zip code
Te,phone Number
t
.B. Pumping ReGord
FS
1. .Date.ofPumping 2. Quantity Pumped:
Date Gallons
3. Type of system. ❑ Cesspool(s) eptic Tank ❑ Tight:Tank
❑
Other(describe):
4. Effluent Tee Filter present? ❑ Yes �6 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f System: r r,
. V �.
6. System um ed B ,.."
Nam, Vehiclecen§e Number
Company..
7. Locatio eIe contents liver isposed::
Sign r of auler Date
http:!/www.mass.gov(dep/wat r/approval8/t5formshttin#inspect
t5form4.doc•06103 Systern'Pornping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of I
System Pumping Record
Form 4 °'
DEP has provided this form for use by local Boards-of Health. 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. Sy�tlon:
forms on the
computer,use i ... ..
only the tab key Address
to move
your
cursor-do not City/Town
use the-return State Zip Code
key. 2. System Owner:--
Name
�I Address(if different from location)
City/Town State Zip Code
4 _ c
Telephone Number
B. Pumping Record W
/
1. Date.of Pumping p a to 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank
❑ Other(describe):
f
4. Effluent Tee Filter present? ❑ Yes °°fVo If yes, was it Gleaned? ❑ Yes ❑ No
5. Condition of st m:
Y
Y ped
m� w
6. S st Pum By .n
Vehicle 4License Number
°
Company -—
7. Locatio where contg,nts a disposed:
Si na' re f Hauler Date
h.ftp://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Re.I cord•Page 1 of 1
i
i
a
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM. OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
A64+5 0"
DATE OF PUMPING: QUANTITY PUMPED : 1 C� GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTE14E EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACH FIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIl4)
SYSTEM PUMPED BY: ateSOn Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFE RRED TO:
i
�C`omirro weI�Zassachusctts sachusetts
4? , .'�/
System P r
System Owner System location
�J
L/ x/h ho-,v
Date of Pum tin r:
1 � Quantity Pumped; ( callous
Cesspool: No Yes Septic 'tank: No 1._1 Yes
System Pumped by: arede"t `e tra - license # v
Contents transferrred to : Greater Lawreme anitary District
Date: _--_-- - Irnspector
I
FORM 4 - SI'STEM PlAHIL``rG RECORD
���
Contttton%cealth of Massachusetts
Massachusetts
sBcrrl 1 urr Reco&
�stem i t3�t tier ---System ocation
4
r
i
Date of Pumping '" "° Quantity Pumped: t
Cesspool: No ,_ 1*es ❑ Sentir Tani.•• Xll Yes
Sy stmt Pumped b.'. - License #:
Contents transferred to:
Date Inspector
4
t�llnlulunrv��llll ur tr111���cllua�I1M
r �
Oyu too 11_!-'"11101110 IQ DOW
I��Mlljll! �IIYI1�1 _._._.__._...._..__._-- ._.. _- ---�---- "1�y41�11M 1.t►c11111,i!
i
I��Ip ur I►Ilnll►I111��
°_ x� -- 1 lilal,l li Y i'ul,ll►���: r�����Ilalll
«« IE,1,1 rr„ I ��✓� 1�'�n I I E3el,liu "I,a„k� Nu I I r��:� ���.-.�
to 1
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--'11111�111� IIIIII�I IIIGII 111 : #lllllll lll�llYl l ill l�Illit __------------
IIIs1,e�:1u1: ---- - — _ __ ----
l
PUMPING TOWN OF NORTH ANDOVER
SYSTEM
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
�de
q
DATE OF PUMPING: b-G-bi QUANTITY PUMPED J SO-G GALLONS
CESSPOOL: No j YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE / EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
TOWN OF �J
SYSTEM PUMPING RECORD
I ' I NOV
DATE: ` `1
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
�voro
f
DATE OF P ING: QU PUMPED : l "+ry GALLONS
CESSPOOL: NO S SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO. G.L.S.D Lowell Waste
o�
TOWN OF /V
DATE
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of hoe)
V�e
DATE OF PII ING: _ IT T P EII > - GALLONS
CESSPOOL- NO SEPTIC TANK: NO — 'S
NATURE OF SERVICE: ROUTINE, --- EMERGENCY
OBSERV'ATIONS4
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIE LD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHER(E L
SYS +M PUMPE II BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: aLo o
Lowell Waste
Commonwealth of Massachusetts ... .. � IVEDj
City/Town of
w System Pumping Record JUN 2 �����
Form 4 d
DEP has provided this form for use by local Boards of Health. O�erforms imay°be a"biat 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
Important:
When filling out 1. System Location:
forms on the w p
computer,use
only the tab key Address
to move your �,"" /`s✓
cursor-do not City/Towm State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town State e ® . ode
Telephone Number
B. Pumping cor
1. Date of Pumping Date 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. Condition of System:
6. System Pum By:
Name Vehicle License Number
Company
7. Location wh content ere osed:
Signature "' Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Op NO�iH\ "
Town of 120Nlzlln Street
OF1710ES OF: o m
. » North Andover,� �� � � � I ®�E �
BUILDING s .. y. MassaChusetis O 1845
CONSERVA CONSERVATION S^cNUSF' I)1\'LtilON(A (0 1 7)085-4775
I JEA1: I I
PLANNING PLANNINC# A t,ONINJUNITY I-)EVELOPMENT
I:,AI;I�fJ I I.I '. Nl�.l ..tit >N, 111R1�(:'IOIt
Rudy .Jwor. ski. 4-12-88
9 tlbt�ot,t: St .
N.Andover_ , Mo . 01845
An inspection of your p.r.oper. Ly on 4--8-88 revealed
no evidence of se p):i.c sy=sLam overflow or malfunction.
sincerely, .
01 r
Whe Graf '
Hn�1lk1_ Dept.