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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASS raD
System Pumping Record -- 2010
JDO
r� Form 4 ��� 9
DEP has provided this form for use by local Boards of Health. �® tTHr Dr',�DO �c rd must
be submitted to the local Board of Health or other approving a
A. Facility Information
Important:
When filling out 1. System Location:
forms the r. l l`r—f
computer,use � Co (� t
( ' � �r�� �
only the tab key Ad ress
to move your rte( o i 60
cursor-do not J� 1
use the return City own State Zip Code
key.
2. System Owner:
C)r Y 0,
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping k /eC
p g Date 2. Quantity Pumped: Gallons
3. :Type of system: ❑ Cesspool(s) D-119eptic Tank ❑ Tight Tank
� ] Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If Yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
h
6. Syststem Pumped By:
� nR- •
e Vehicle License Number
Company
7. Location where contents were disposed:
r
+t c o 1���
ign ure of Hauler Date
http:/Avww.mass.gov/dep/water/approvals/t5forms.htm#inspect
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