HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 270 SOUTH BRADFORD STREET 5/7/2025 Commonwealth of MassachusettsTown of Noah Andover
City/Town of MAY 15 2025
System Pumping Record Form 4 Hea I 11h 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 Ihis form, check with your
local Board of Health to determine the form Ihey use, The System Pumping Record must be submitted to
the local Board of Health or other approving authority within '14 days from the purnping date in
accordance with 310 CMR 15351, ............
HOUSE: fr ack side rear eft(�
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: tj n d P
(Illlng out forms 1. System Location,
on(hp computer,
use only the tab 2-7d CX -
----
key to move yot,it Address
cursor-do not AA<�� MA
USe the return -------------
-Ciryffown state Zip Code
2, System Own pr-
Name
Address(If different from location)
MA
City/Town state Zip Code
—A—CV—
Telephone Number
B. Pumping Record
1, Date of Pumping
2. Quantity Purnped�
Dale Gallons
3. Component: ❑ cesspool(s) Septic Tank ❑ 'Tight Tank ❑ Grease Trap
0 Other (describe): --------—-----
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? ❑ Yes L7 No
5. Observed condition of component pumped,
6. System Pumped By.
2ave TIDey Mass lA-A95E< Mess 11 A D 3 1 Z
Name Vehicle License N mber
e��feson Enterprises, Inc.
Company
7, where contents were disposed:
I L YJ
........-------
-§�Inalure of Hauler pale
Tlg—na`ture-ofReceiving Facility (orfacility-recei-pl) Date
Worrn4.doc• 11112 Sys((-.,n)Pumping Record paqc, I of 1