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t5rorm4.doc- 03/05
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
QBP has provided this form for use by tocai Boards Qf Flealth. Other forme may be used, but the
Information must be substantially the Mile as that provided here. Before using this forrn, check with your
local Board of Health to determine the forrn 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 $10 CIVIR 15.351.
A. Facility Information
1, System Location;
5Z-L:
A reN
City/Town
2. System wner:
Name
Address (if different from tocation)
7dityr'rot".v7"---- • —
.a*tat'e ZIO-C"OFe'-
.-
Tefeptfone Number
2-4-41r.
B. Pumping Record
1, Date of Pumping
(g5-
Date. 2. Quantity Pumped;
Gallons.
3, Type of system: E Cesspool(s) Ai Septic Tank 1:] Tight Tank Ei Grease Trap
El Other (describe): •—• -•.. •
4. Effluent Tee Filter present? Ej Yes E No
5. Condition of S s
company
7. Location where isposed:
sVich
nature1-fa
If yes, was It cleaned? Ye$ CD No
vehicle License Number
Dae
Signature of Receiving Facility Date
System Pumping Record - Page 1 or 1