HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 CEDAR LANE 7/1/2025 Town of Noah Andover
` Commouvealth of Massachusetts
c, City/Town of _ JUL 2025
Re System Purn yin Record
= 1° co
r f Form 4 Health Department
DE P has provided this form for use by local Boards of I--iealth. Other forms may be used, but the
nformation rnust 5e st,ibsf,anfially the same 2s kihaf provided here Before using this forn7, check with your
local Boan.1 of Healli7 to determine the form they use The System Purnping Record must be submitted to
the local [hoard of Health or other approving authority within 14 days from -.he purnping date in
accordance with 310 CMR 15,351 ------ ------ -----------
HOUSE: f r o n t a c .. s i d e e I e ft
A. Facility Information aUiLDlNGi fronC back side rear left rif,
Important.When
DECK: under
(Ming out forms 1. System Location
on ML compuler,
ri (ram Z
use Only Ole tab �'
key tc move yom Address �°/
cursor -do nol �. /' MA � -
U,5e the iePurn r " dry " � -._ _ _. _. __ _.
kq y C:IIylro"n t"e ZIp Code
2 ;~yystE;n' owrlrer
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Address (If difierenl from IocaHan) _. .--- -.,_..... .
MA
C;IIy(rt7wn State ZIp Co e
_ " . _ .
Telephone Nurnber
8, Purnping Record
1, Cate of Purnping _ _.___------_._- 2. Quantity Pumped:
Dale Gallons
I Component: ] Cesspool(s) _ eptic Tank [_) -right Tank Grease Trap
�) Other (describe):
4. Effluent Fee filter present? [._� Yes Fir. o _ If yes, was it cleaned? ❑ Yes (] fVo
5. Observed condition of con-iponenl puipperi
5. SysC� �r
)rnf.)ed By
CsivM ass 1�,A95E asp, 1AD3,1 .Narn Vehicle License Nurnbef
�nferE7rises, Inc ,.
c romp my _
1 where contents were dispor.ed
as
Si(nature oI H ai Ief — date ..
�`I<Inra9ure of F-tecewing Facility(Or afiach facility (r2crir>t) Date
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