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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
C D
JUL 1 2 20'
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:i
ktn
Address
North Andover
City/Town Stale Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
State Zip Code
Telephone Number
V73 1' 57.
1. 2. Quantity Pumped:
Date of Pumping
Date Gallons
3. Component: Lil Cesspool(s) El--8-e-ptic Tank 111 Tight Tank 11] Grease Trap
LI Other (describe):
4. Effluent Tee Filter present? El Yes Er-Nk:: If yes, was it cleaned? El Yes I] No
5. Observed condition of component pumped:
6. System Pumped r,
(v7
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
Signature of
Vehicle License Number
Date
acility (or attach facility receipt) Dat
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