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Commonwealth of Massachusetts
City/Town of NO ANDOVER
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 Rec d must be submitted to
the local Board of Health or other approving authority within 14 days from s1,64 ng date in
accordance with 310 CMR 15.351.
k1\1
A. Facility Information
1. System Loc tion:
c)A_D.,nr)_ a
Address
No Andover
City/Town
2. System Qwner:
n_
State Zip Code
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1.
Date of Pumping
2. Quantity Pumped:
Date
3. Component: 111 Cesspool(s) Y'Septic Tank
0 Other (describe):
4. Effluent Tee Filter present? D Yes 0 No
5. Observed condition of component pumped:
3Q 0 r
6. System Pumped By:
r
Va
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mills adford ma
nature auler
Signature of Receiving Facility (or attach facility receipt)
Ej Tight Tank
Gallons
0 Grease Trap
If yes, was it cleaned? 111 Yes 0 No
Vehicle License Number
Date
Date
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