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MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
60 PARK STREET 0 ANDOVER. MASSACHUSETTS 01810 4 TEL. (617) 475-3553. 373-5721
Commonwealth of Massachusetts
Town of North Andover
System Pumping Record
System Owner & Address:
Cathy Gavriel
10 Old Cart Way
North Andover, Ma 01845
Date of Pumping:
Type of System:
June 14, 2013
Septic tank
Location of System: Rear yard
Gallons Pumped: 1500 gallons JUL 0 8 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
System Pumped By:
John Zanni Pumping Co. LLC
5 Hallberg Park
North Reading, Ma 01864
License #: BHP -2013-0067
Contents Transferred to: Greater Lawrence Sanitary District
Date: June 14, 2013
Pumping Technician: JN
This is proprietary and confidential information that may be used only by the
Board of Health for regulatory purposes
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FML APPROVAL Dr4�� Z ��
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
�
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHU ermw
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The Sys
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
Address
9\,n c/� c e �.- Z- 1d A-
City/Town State Zip Code
2. Svstem Owner:
r3 -V Ft,i e
Name
Address (if different from location)
City/Town
B. Pumping Record
State
Telephone Number
1. Date of Pumping / 0 2. Quantity Pumped
Date
3. Type of system: ❑ Cesspool(s) Septic Tank
❑ Other (describe): —
4. Effluent Tee Filter present? ❑ Yes [2 -No
5. Condition of
N
Zip Code
iS—t--o
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
6. System Pumped By:
7 C-
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1