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W �I
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOV
Form 4
RECEIVED
07 20IJ
TOWN OF NORTH ANDOVL ,
HEALTH DEPARTMENT„
DEP has provided this form for use by local Boards of Health. Other forms may be used, but 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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
_SQ S , 3U'1 9C oc% I?
C4_.
— ---- - -
Address
CityfTown
State
Zip Code
2. System Owner:
q� ct-L ry? a -v
Name
`
Address (if different from location)
City/Town
State Zip Code
q 7 69,5 --
Telephone Number
B. Pumping Record
a _ /
0-0
1. Date of Pumping p e
2. Quantity Pumped:
Gallo ss
b,SepticTank
3. Type of system: ❑ Cesspool(s) ❑TightTank
\
E]Grease Trap
❑ Other (describe):
--- — — -
4. Effluent Tee Filter present? ❑ Yes�No
If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System:
0
6. System Pumped By:/ n''
ol
Name Vehicle Licgnse Number
(.rte in d M.S.D.
Company
tdOVer, MA.
7. Location where contents were disposed:
0�z �-
Sig a of Hauler
gnature of.Receiving Facility
Date
Date
t5fonn4.doc• 03106 System Pumping Record • Page 1 of 1
ILI\ Commonwealth of Massachusetts r
CityfTown of �/��� �� ae-/Z DEC 0 6 2004
System Pumping Record
TOVIN C� �..�`.Tr A%DOVER
Form 4
}„
DEP has provided this form for use by local Board of Health. Other forms may be used, but the
information must be substantially the same as tha provided here. Before using this form, check with your
local Board of Health to determine the form they se. The System Pumping Record must be submitted to
the local Board of Health or other approvin . aut ority.
A. Facility Information
Important:
When filling out 1. Systtemm, Location:
s
formon the —1��% S
computer, use -+
only the tab key Address
to move yourA
cursor -do not "oW� ��� Stat Zip Code
use the return
key. 2. System Owner
t ./ / / ♦ vr♦ �E
Name
y
-: Address Cd different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Dat
2. Quantity Pumped: Gallons
®
Cesspool(s) eptic Tank ❑ Tight Tank
4, Effluent Tee Filter present? ❑ Yes L1�t10 If yes, was it cleaned? E] Yes El No
5. Condition of System:
bIfS�
S. System Pumped By:
N
mpany
7. Location where contents were
Vehide License Number
t5fornA.doc- 06103` System Pumping Record • Page 1 of 1