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210/090.6-0046-0000.0 }
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Commonwealth of Massachusetts REEIVED
�N City/Town of NORTH ANDOVER MASSA HUSET
System Pumping Record JUN o 4 200
Form 4
- " TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use n ea 1 I sckyYl �-1
only the tab key Address
to move your
cursor-do not �) S
use the return City/Town State Zip Code
key. 2 System Owner:
Name
Address(if different from location)
City/Town State c Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat I J� �� 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [2"Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
__ Gooch
6. System Pumped By:
J i-,rn I � _ ��� Cl
Name Vehicle License Number
�� �►v�( �ny►�on�men�C�L
Company
7. Location where contents were disposed:
_j7—/,9(—0 01 --
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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