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Commonwealth of Massachusetts
City/Town of North Andover
Syste Pu ping Record
Form 4
' I
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 umping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
Address
•tnn Ln
North Andover
City/Town
State
Zip Code
2. System 0 ner:
COS n--m
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Component:
8 -CI k
Date
State
Telephone Number
4/0
uantity Pumped:
15' (7z)
Gallons
11 Cesspool(s) I Septic Tank 111 Tight Tank LI Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? El Yes Er7s--INo
5. Observed condition of componynt pumped:
66 Ilk
stem Pumped/Byz
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
If yes, was it cleaned? El Yes 0 No
7. Location where contents were disposed:
21 so mill sr6fo ma
Sir nature of Hauler
gnature of Receiving Facility (or
ttach facility receipt)
Vehicle License Number
Date
Date
t5form4.doc• 11/12
System Pumping Record • Page 1 of 1