HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 VEST WAY 7/2/2026 Commonwealth of Massachusetts Town of Noah Andover
City/Town of
System Pumping Record JUL - 6 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other fJt8ma-'y'qAAPAdm1ent
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 15.351.
e
HOUSE: fro4."�ack side rear
ft right
A. Facility Information BUILDING: 'front back side rear I<e right
Important:When DECK: under
filling out forms 1. System Locatio
on the computer, L
use only the tab 'I a, V
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
'�❑ 2, System Ownpr:
1<q�(l
Name
Address(if different from location)
MA
City/Town State ^ ®❑' �ode
-telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date 'Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank 7 Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes ffT--No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped,
6. System Pumped By:
5esonDave Tine Mass 1AA95E Mass 1AD31Z
Name Vehicle License N!umb�er �����
Enterprises, Inc.
�t_ — "
Company e";
7. Location where contents were disposed:
GLSD
Signature of Hauler ��
Date
7
SignatureReceiving of R ving cility For attach facility receipt) Date
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