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City/TownMA
System Pumping
Mr
Foam
DEP has provided this form for use by local Boards of Health. The System:Pumpling Record must
be ed to the local Board of Health or other approving authority.
A. Facility Information
Important:
When tilling out 1. System tion".
forms on the
computer,use 153 5" 6mc-x%�:-Q 5
only,the tab key Address
to move your
North Andover MA 0 11 845,
cursor-do not City/Tom ;state Zip Cody
use the return
key
2. System Owner:
s.
M� Name
I
Address(if different from location)
f
Cityffovm State Zip Code
c .*7c -7 6 0
Telephone um r
B. Pumping Record
S, s 1'01 T5 00
1. Date of Pumping Sl—t� 2. Quantity Gallons
I
. 1
I hype of system: ' cesspool(s) [2eS6pt c'Tank El Tight Tank
a
E]
Other(describe)
. Effluent Tee Filter resent? [I Yes P�rNo If yes,was it cleaned? Yes No
5. Condition System:
Wo
g=Ae'11 V\4
6. System m e #'-,
Name Vehicle License Number
Wind River Environmental
Company
ry
7. f
Location where contents weredisposed: Ipswich, MA.,,
Signa,tuk,of Hauler Date
t5form4.docs S,ystem Pumping Record 'Page I of 1