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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
.ECEVED
FEB 14 Z017
TOWN OF NORTH ANDOVER
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 Location:
-4dress
North Andover
City/Town State Zip Code
2. System Owner:
Address (if differen , rom loca on)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date
— VT_ 2. uantity Pumped: i5 CR)
Gallons
3. Comp ent: 11 Cesspool(s) u - eptic Tank III Tight Tank El Grease Trap
Other (describe):
4. Effluent Tee Filter present? 111 Yes 2 No If yes, was it cleaned? LI Yes LI No
5. Observed condition of co ponent pumped:
6. SytTh Pumped B
Name
Stewarts Septic 58 So Kimball St B
Company
7. Location where contents were disposed:
20 o mill st brad d ma
3 3
Vehicle License Number
Sign ture of Hauler Date
Signature of Receiving Facility (or attach facility
eceipt)
Date
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