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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
1°0
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:
\ Mal\ L--()
Address -
North Andover
City/Town
2. System Ow
....3k_A
Name
er:
Address (if different from location)
City/Town
State
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
- 5 -
Date
El Cesspool(s)
El Other (describe):
4 4, Effluent Tee Filter present? E1 Yes No
5. Observed condition of component pumped:
6. Syst? umped By:
trIV\
Name
2. Quantity Pumped:
Septic Tank
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 dford ma
Signature 0a
Signature of Receiving Facility (or attach facility receipt)
°
Gallons
El Tight Tank 111 Grease Trap
If yes, was it cleaned? El Yes
Vehicle License Number
Date
Date
No
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1