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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
Form 4
V
(*IP 2 5 2(17
TOWN OF NORTH ANDO
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:
1770 SALEM STREET
Address
NORTH ANDOVER MA
City/Town State
2. System Owner:
KRISTEN WATSON
Name
Address (if different from location)
City/Town
01845
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
9/13/17
Date
LI Cesspool(s)
LII Other (describe):
2. Quantity Pumped:
2000
Gallons
Septic Tank rj Tight Tank El Grease Trap
4. Effluent Tee Filter present? 111 Yes El
No If yes, was it cleaned? 11 Yes ID No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIER
Name
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
H79406
Vehicle License Number
9/13/17
Date
Date
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