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RE��'VED
� Commonwealth of Massachusetts
= City/Town of VU1- ° 9 2013
System Pumping Record NORTH ANDOV�
.4
Form 4 -
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
Important:
When filling out 1
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key. 2
City/Town State Zip Code
Ow1ner:
.>�' \
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
0 -
State(o
f.-7� wZipfyodg,�(,
TelephoneNumber
Date 2. Quantity Pumped
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes KNo
5. Condition of System:
6. System Pumped By:
Name
Company—��,. —
7. Location wherecon Ned:
of Receiving F
Gall6�
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
4?r°7/; 1
Vehicle License Number
G.L.S.D. A Date
A c-r0v6-f, MA Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1