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Commonwealth of Massachusetts Waal',
City/Town of NORTH ANDOVER MASSACHUS TI'System Pumping Record 0inn
Form 4
DEP has provided this form for use by local Boards of Health. The Syst r WN
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
Address �► 1 � ^ � r - ,
Cityrrown St a e Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
State
Telephone Number
B. Pumping Record
Qb Ito
1. Date of Pumping Date 2. Quantity Pumped
3. Type of system: ❑ Cesspool(s) /Septic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
Zip Code
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
stem Pumped
ame Vehicle License Number
1.
Company
mature of Hauler
http:/Mww.mass.gov/dep/water/approvaistt5forrns.htm#inspect
t5fonn4.doa 06/03
System Pumping Record • Page 1 of 1
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