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;CommonW'ealth of Massachusetts
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:City/ 'own of,NORTH ANDOVER MASSvER
System' Pum 1n Record ^T
FOr m'14
DEP has proylded,this form for use by local Boards of Health. The System Pumping Record mua
be submitted to the local Board of Health or other approving authority,
A. Facility Information
1 . 1, NstR Locatl
Y Add
t I
C 1y/rown State
Zip Code
2, System Owner
Name
Address(If different from locauon)
i
Clty/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping P 9 ' 7//f)
a 2. Quantity Pumped: 1
• � Gallons j
3, t Type of system; . ❑ cesspool($) �J Septic Tank ❑ Tight Tank t
' {] Other(describe):
4. Effluent TeeFilterpresent? ❑ Yes ❑ No If yes,"was it cleaned? ❑ Yes ❑ No
5. Condition of System: (:
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SYMPumped By:
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� �5(� Ve�cle License Number
Company,:. : ; j
7,: Locatl0 where contents were disposed:
4:.: 1Pon8tLUurQQr1H4aWer,, I
Date
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3 ° ^•. System Pumping Record•Page 1 of 1