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W I
Commonwealth of Massachusetts (" EIVED
City/Town of .t
System Pumping Record APR 2 2008
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms maybeused,ut 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 Location:
(;--oc')�
Address ^ A
City/Town
Jp�State—JUCK-��
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
C -d
Zip Code
SI Zip Code
('� 7 /,S -77a
Te 'phone Number
�
.... . QuantityPumped: Datep Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes L2 -14o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System- / /. /G �S
6. Syst By:
Name Vehicle License Number
Company
7. Locat7iwhire conte f,
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1