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// 210/047.0-0095-0000.0 � \`
Commonwealth of Massachusetts -- - - -
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City/Town of RECEIVED
System Pumping Record OCT 1 g zoll
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Form 4 TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other form HEALTH DEPATMNT
,
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 Location: Left/Right front of house, Left/Right rear of house, Left/ I ht sid of house eft/
Right side of buildin , Left/Right front of building, Left/Right rear of hijilding, Under deck
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Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
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Telephone Nbmb,er
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B. Pumping Record
1. Date of Pumping Dae 2 uantity Pumped: r•S�C�
Gallons
3. Type of system: ❑ Cess ool s Septic Tank ❑ Ti ht Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: n '
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
SignAttie 4 Haule Date
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