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Commonwealth of Massachusetts
-- - City/Town ®f North Andover
a
a
System Pumping Record TOWN OF r P
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 1. System Location:
forms on the ' (�
computer, use J - I -- -J
only the tab key Address
to move your N.Andover Ma 01845
cursor-do not -- -
use the return City/Town State Zi p Code
key.
2.2. System Owner:
r - - t
Name
-- - ------ -- ------ ------ -----
ean Address(if different from location)
City/Town State Zip Code
------- -- -------- ----
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: -
C7ate Gallons
3. Type of system: ❑ Cesspool(s) eptic 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:
- - -- — - - --- -....---
6. S stem Pumped By:
cl. --
ame Vehicle License Number
Stewart's Septic Service
Company - —
7. Location where contents were disposed:
Ste rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signat re of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03106 System Pumping Record•Page 1 of 1
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