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MOO
4,14
11001
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
Form 4
oC ?, 5 101
TOWN OF NORT1-1 ANDOVER
1-01.1.1-i 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
System Location:
67 SHERWOOD DRIVE
Address
NORTH ANDOVER MA
State
City/Town
2, System Owner:
NICOLE GIGQUINTO
Name
Address (if different from location)
City/Town
State
01845
Zip Code
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
10/17/17
Date
2. Quantity Pumped:
1500
Gallons
3, Component: 0 Cesspool(s) Septic Tank 0 Tight Tank 0 Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 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
If yes, was it cleaned? 0 Yes El No
H79406
Vehicle License Number
Signature of1;yliiier
Signature of Receiving Facility (or attach facility receipt)
10/17/17
Date
Date
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