HomeMy WebLinkAboutMiscellaneous - 205 CAMPBELL ROAD 10/19/2015 Commonwealth of Massachusetts
7qrd 0
City/Town of
System Pumping Record
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 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 forms 1. System of
on the computer,
use only the tab
key to move your Add s
cursor-do not
use the return
4Cityv own -Late)— Zip Code
key.
2. System Owner: R E C1 IVED
it
/W 4
Name
iehan
Address(if different from location)
"I'Ll fi JL� 1 iu m
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 1660
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System'. .,
6. System Pumpe 15 By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stew-art's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record-Page 1 of 1
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Commonwealth of Massachusetts
City/Town of North
Syst pumping Record
`
Form zK
» for use by local Boards of Health. Other forms may beuawd y but
the e
form, check
with your
DEp has pr»»id d this idedhere� DeforeusinSthio
information must be substantially the saneasthatpro» « pD « cordmust beoubm\�edto
local Board cfMean h to determine the form they use. The System pm \ng,date in
the local Board of Health �r otherapprov\nyauthor\tyv\th\n14daysfromtnep ump
�
accordance with 310CK8R16351 �
A. Facility information
important When 1 System Location: �
filling out forms
on the computer,
use only the tab
key Address
� Ma
cursor-dmnm North Angm»er �S�� Zip Code
use the return
_'.
2. System Owner:
Address(if different from location)
State Zip Code
=Telephone Number
B. pumping Record
1. Dateofpumping Yate 2. Quantity Pumped: Gallons
[] Tight Tank Grease Trap
E] Cesspool(s) eptic Tank
3. Type of system: O"S
F� Other ---�
�� (describe):
4. Effluent Tee Filter present? Ej Yes O No -if yes, was ncl' a hed? Yes No
5. Condition ofSystem: �
8. System pumped By:
Name
company `
\
7, Location where contents were disposed:
Stewaff s Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
ignatUTeofHauler Date
ignature of Receiving Facility Date
system pump in 9 Record-Page
t5fonn4.uoc 03106
Commonwealth of MassachUsetts
City/Town of NORTH ANDOVER,
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Hea6.�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 purnping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
$
on the computer,
use only the tab -------
key to move your Ad ress
Cursor-do not
use the return
key. City/Town Zip Code
2. System Owner:,,,
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 2. Quantity Pumped:I. Date of Pumping Date G'allllons
3. Type of system: r] Cesspool(s) .1;1'oSeptic Tank [I Tight-rank 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
Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Si iet r e_1116 ilau". r Date
Signifor6'6f Receiving Facility Date
t5form4.doc•03/06 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover q l
w System Pumping Record
r
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 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 forms 1. System Location:
on the computer, ._J 7
use only the tab C �.�1.�_ ..—
key to move your Address
cursor-do not North Andover Ma 01845
use the return _ _ — --
key. City/Town State Zip Code
2. System Owner:
Name r
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pat bd-
2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): _-
4. Effluent Tee Filter present? ❑ Yes E/No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6.(:: ystem Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ignature f Hauler
Signatkr o eceiving Fac lity Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
DelleChiaie Pamela
From: Oo|leCh|aie, Pamela
Sent: 2009 10:19 AM
|o: /uet
Subject: 2U5 Campbell Road -Septic File from the Health Department of the Town uf North Andover
Attachments: 8KMBT_80008030311030.pdf
Hello Mrs. Harrison,
|t was a pleasure to speak with you today at the counter. Aa | mentioned, here is the scanned copy of your file for your
records. �
Please call the office if you have any questions.
Pamela Dclte.Cbaic
Health Department Assistant
Town of North Andover
g70.b88.g54O ' Phone
g78.G88.8470'Fax
-
From: nonypk/@vouncopier.conn [mna|ho:noneply@vourcopier.com]
Sent: Tuesday, March 03/ 2009 11:04 AM
To: DaUeChia|e, Pamela
Subject: Message from KMBT`6UO
1
r
ii ii 2007
x' is
Comrrsonwealth of Massachus t
I'(ANN
")k' Clttl y
% dAumvinz Mass achusetts .��� , r� a :
stem Record
Systcm Owao�' n Syst Loc:ation
Type; 'Emergency 0 Routine
Cesspool: No 0 Yes 0 Septic Tank; No 0 Yeses
Date of Pumping Quantity Pumped gallons
System Pumped.by (Company) Permit #
Contents transferred to;
Contents disposed at;
l
Date �Pumper Signature
Conditi of em/ ther comments; '
Commonwealth of Massachusetts
+� City/Town of NORTH N�► C H U ,;
System Pumping Record 1
Form 4 AUG 0 4 MoS
DIP has provided this form for use by local Boards of Health. The ��;�
be submitted to the local Board of Health or other approving authori y [ �urnptngecgrc� u;
i
A. Facility Information — --- ------_--
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address
--
c move your
cursor-do not - --
Cit /Town
use the return State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
C ity/Town
State Zip Code
Telephone Number
B. Pumping Renard
1. Date of Pumping -- - 2. Quantity Pumped:
Date y Gallons
Type of system: ❑ Cesspool(s) E�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. Sy em Pumped By:
Name
�� vehicle License Number
Company
T Location where contents were disposed:
_> �z. G r
S� ature of Haul
http://www.mass,gov/dep/water/zrovals/t5forms.htm#inspect date -
t5form4.doc,06/03
System Pumping Record • Page 1 of 1
1
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. TO`WN, F`NTH ZOVER C% Con YST
DATE
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
c" j
DATE OF PUMPFN �
�QUANI'ITY'PUMPED
i
CESSPOOL NO SEPTIC TANY, NO YES_
NATURE OF SERVICE;%RQti EMERGENCY
OBSERVATIONS:
GOOD CONDITION'` ` FULL TO COVER
4AAVVY OREASE : BAFFLES IN DACE
LEACHRIELD RUNBACK
EXCESSNE SOLIDS, FLOODED
SOLID CARRYOVERS OTHER EXPLAIN
SYSTEM PUMPED BY
COMMENTS;
CONTENTS TRANSFERR D ':
• u p p ?fit. ryxr$ ��IY i r ,1'lc,. „ ,v '. .+ ..
WNOFNORTH'
AND OVER
r
;FS EM UWNFR & ADDRUS SYSTEM LOCATION -
IlIvr d (Qzumnle; lef'l front of housr)
C > r �
OV
U:�'I'G OF PUMI'INC; ` r�z�" v
QUANTITY UM P Q. D4L6 C' ' � l
;SI'UULG`NO , YES ,SEPTIC TANK; NO YES
------
MATURE OFSERYICE, ROUTINE. EMERCENCY
I,�RRYAT10NS
( UUD CUN011'10N, PULL-TO COYEk
FI!?AYY GR ASG . OAMSS IN N,ACI?
R0O,TS LEACHFIELD RUNDAC'K,,,
cxcESSWE SOLIDS FLOODED
S01 IU5 'CA RRYOYER' p HR( (EXPLA.IN)
>v.' 'r'lnm PUMPC aY
'r
c U);I!yl LNTS:
TRAW( Cl RRED TO;
I
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
-'�l'STEM OWNER & ADDRESS SYSTEM LOCATION --
(example: left front of house)
DATE OF PUMPING: QUANTITY PUMPED ��������° GALLO:N'S
C'I,'SSPOOL: NO — YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE �� �' EMERGENCY
OBSERVATIONS:
GOOD CONDITION �' FULL TO COVED
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
COON I'E'NTS TRANSFERRED TO:
1
k
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
1+X.
(example: le front of house)
1, c.
' DATE OF PUMPING: ....... 6 I QUANTITY PUMPED � � �"��� GALLONS
CESSPOOL: NO � °
YES SEPTIC TANK: NO YES
NATURE
OF SERVICE: ROUTINE
BSERVATIONS:
//EMERGENCY
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE _
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER (EXPLAIN)
9
; SYSTEM HUMPED BY: C/f d`v
{
�OMMENTS:.
y �
'' CONTENTS TRANSFERRED TO.
y
t��
t. 1
i