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�L\ Commonwealth of Massachusetts
City/Town of
System Pumping Record " toil
Form 4
M SOWN Ci" NORTH ANDOVER
'HEAITH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other for useG, out 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.
A. Facility Information
1. System LocationRig ntofho , fr Left / Right rear of house, Left / right side of house, LeftRight side of buil,Left / Right front of building, Left / Right rear of building, Under deck
Address (,
VC�t1�
City/Town State Zip Code
2. System Owner: �� b
Name V
Address (if different from
City/Town
State Zip Code
Q--Or7
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qu tity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑Ti ht Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition pf $yster����`�
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locaf h nt
7G. L S.
SignAtufe qt Haule
t5form4.doc• 06/03
were disposed:
)well Waste Water
F5821
Vehicle License Number
Date
--6 -- j f
System Pumping Record . Page 1 of 1
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