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HEALTH
Commonwealth Of Massachusettr�
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System Pumping Record
Form 4
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pBP' has provided this form for use by local Boards of Health.
be submitted to the. Icacal Board of Health or other approving
A. Facility Info
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1, SYstom Location:
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�. Pumpinq Record -
I. Date of Pumping
Date 2. quantity Pumped: J v
a. Type of system: Gauona
❑ Cesspool(s) Septic Tank
❑Tight Tank
❑ Other (describe): ---
4. Efiluent'Tee Filter.present? Ej ----�
Yes ❑ No if yes, was it Cleaned?
5. Condition of S ❑ Yes ElNo
Ystem:
6. System p lit ed By,
ROOTER-MAN
d1na 1 12 EAST DRACUT ROAD
METHUEN, MA 01844
7. Location wljeregntents were disposed;
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Vehiclle Llcenso Nurrb,er
Date
�Ystem Pumping Record • Page q of 'I
Commonwealth of Massach setts
City/Town of AM CSW a K
System Pumping Record
RECEIVED
JUL 14 2010
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Facility Information:
System Location:
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Address
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City/Town State Zip Code
System Owner:
Name:
Adress (if different from location of pump)
City/Town State Zip Code
x'79 - qqg -53Z
Telephone Number
Pumping Record
Date of Pumping 6D// 6� / v Quantity Pumped_, W gallons
Type of System–X—Septic Tank Grease Trap Other (what)
System Pumped by: ba 1/ L 1 Y7 6 �Z
Company: ROOTER -MAN 12 East Dracut Rd., Methuen, MA 01844
Location where contents were disposed: 4 j 'S D
Signature of Hauler kL Date 0 (� b