HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 82 LIBERTY STREET 5/12/2026 Commonwealth of Massachusetts Town of Noah Andover
City/Town of
M MAY 18 2026
System Pumping Record
Form 4
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 CIVIR 15.351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return D
key. City/Town
State Zip-Code
2. System Owner:
D 0C
Name
Address(if different from location)
157ftyf�Town State
Zip code
Telephone N-umber
B. Pumping Record
1. Date of Pumping
Date Z&-- 2. Quantity Pumped:
3. Component: F-1 Cesspool(s) ❑ Septic Tank 0 Tight Tank 0 Grease Trap
D Other(describe):
4. Effluent Tee Filter present? [:] Yes El No If yes, was it cleaned? n Yes 0 No
5. Observed condition Of component Pumped:
6. Syste Pumped By:
Name
Vehicle License N6-m-bler -
Compan
7. Location where contents were disposed:
C) L
v
Sign re, f auler Date
Signature of Receiving Facility(or attach facility-receipt)
t5fbrm4.doce 11/12
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