HomeMy WebLinkAbout- - Septic Pumping Slip - 135 FOSTER STREET 8/14/2026 Commonwealth of Massachusetts Town of Noah Andover
City/Town of
x SEP 14 2026
System Pumping Record
v Health Department
Farm 4
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 16.351. _._._____........___
HOUSE: front back side rear le right
A. Facility Information BUILDING: front back side rear left Information "t
important:When DECK: udder
filling out forms 1. System Locations:J
on the computer, j L
use only the tab _._
key to move your Address
cursor-do not MA
use the return vl k v _.__— _.
key. City/Town State Zip Code
Y`
2. System Owner
� ;; Name
E-1
/ �1
Address (if different from location)
MA _
CityCTown State y ` � Zip Code
Telephone Number
I3. Pumping Record � jl"
1. Date of Purnping 2. Quantity Pumped: ._.__
Date Gallons
3. Component: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe);
4, Effluent Tee Filter present? L] Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu ped:
6. C
mped By:
e Mass 1AA95E Mass 1AD31Z
J _—_ _. _
Vehicle License Numbenterprises, Inc_
7. ocation where c tongs were disposed:
GLSD
Signature of Hauler
Date �.____-------
Signature of Recetving Facility(or attach facility receipt) Date
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