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ISform4.doc-
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
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140AI
DEP has provided this form for use by local Boards of Health. Other forms may be used, Out 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 Systc4_,Bation:
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A:trTr''
--ort
City/Town
(Yz-e/e-.5-Xci
Address (if different from location)
City/Town
State
....... .
State ,
Telephone Number
zi•P'didi —
B. Pumping Record
I. Date of Pumping
3- Type of system: E3 CesSpooks)
Other (describe):
4. Effluent Tee Filter present? 0 Yes
5. Condition of Sys
6. System
Name
Company
7. Location where c
Slgnatu
81 17
Signature of Receiving Facility
2. Quantity Pumped:
14
ptic Tank 0 Tight Tank 0 Grease Trap
No If yea, was It cleaned? 0 Yes 0 No
Vehicle License Number
WNW
oder St ----
A430133t e .
Dat
?382
Date
4,4
System Pumping Rewret • po941 or