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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
08 System Pumping Record
Form 4
M
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
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
1. System Location:
Address —� --
tea• ce.���
City/Town
2. System Owner:
Name
Addross (if
Citylown MAY 1 1 2006
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
'14�1 '
State
Zip Code
State Zip Code
Telephone Number
Dat 2. Quantity Pumped
Cesspool(s) 61eptic Tank
y/&2o
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes �No If yes, was it cleaned? ElYes ElNo
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Company
7. Location where contents were disposed:
0�20 '-�) . . `Sf
Sig ture of Hau
http://www. mass.gov/dep/water/aprovals/t5forms. htm#inspect
uare
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1