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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
Form 4
10
DEP has provided this form for use by local Boards of Health. Other forms maybe 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.
(31, col
0-
A. Facility Information
1.
System Location:
110 BROOKVIEW DRIVE
Address
NORTH ANDOVER
City/Town
2. System Owner:
ROBERT SWEENEY
Name
Address (if different from location)
MA
State
City/Town
01845
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
7/25/17
Date
3 Component: LI Cesspool(s)
E] Other (describe):
4. Effluent Tee Filter present? 1:1 Yes El No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIER
1500
2. Quantity Pumped: Gallons
Septic Tank El Tight Tank El Grease Trap
If yes, was it cleaned? 1:1 Yes El No
Name
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
Signature'of Hauler
H79406
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt)
7/25/17
Date
Date
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