HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1001 JOHNSON STREET 6/11/2026 1�\ Commonwealth of Massachusetts
To
City/Town of � re of Noah Andover
SystemPurpling Record
Farm 4 JUL 7 2026
DEP has provided this form for use by local Boards of Health.Other farms may be used, but the
information must be substantially the same as that provided here. B JA�ffl*
th you
local Board of Health to determine the they use.The System P c r� us"esu%ifted tb
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
Important:When
filling out forms 1. System Location
on the computer, d,�ry
use only the tab _ �._. IL/
key to move your Address
use the returnt State
Zip Code
key. Cityftown
2. System Owner:
Andress.of different from location)
State Zip Code
..'telephone NumberA--
B. Pumping Record
p J Date ? 2. Quantity Pumped: Gallons-
rain
1, gate of Pumping
. Component: ❑ Cesspool(s) c Septi�. Tank. [1 Tight Tank. a Grease Trap
E] Other(describe):
4. Effluent Tee Filter present's El Ye�' o if yes,was it cleaned? 0 `des F1 No
condition of pumped:
5. Observed �
6. System Pumped By:
Vehicle License Number
ttame t
ompany
7. Location were contents were disposed:
Signature of Hau er gate
Signature of Ro ecevim Facility(or attach facility receipt)_
Systems Pumping Record!Page 1
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