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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
ECE
"IB 1 4 ?011
TOWN oF NuK H ANOOVER
HEALTH DEPARTMENT
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
1. System Locatiop:
S
Address
North Andover
City/Town State Zip Code
2. System Owner:
CSILSa Vapti
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
Date
2. Quantity Pumped:
LI Cesspool(s) Bleptic Tank
LI Other (describe):
4. Effluent Tee Filter present? El Yes 0 No
i5. Observed c ndition of component pumped:
6. System Pum
NIkt,
ed By:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st br&iford m
SigitiJfe orHau
Signature of Receiving F ility (or attach facility receipt)
AS-o0
Gallons
0 Tight Tank 0 Grease Trap
If yes, was it cleaned? 0 Yes LI No
Vehicle License Number
—)
Date
Date
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