HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 222 BRIDGES LANE 12/13/2021 local Board of Health to determine the forrh they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Inforri�ation
1. System Location: Left/Right front of house, Left/Right re user, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/ ght rear if building, Under deck
on the computer,
use only the tab
key to move your A less /
cursor return
not MA O`use the return
key. Cr !Town SkV.&7—
tate Zip Code
2. System Owner:
Name
AIM
Address(if different from location)
MA '
Cityrrown State Zip Code
Telephone Number
B. Pumping Record 1. Date of P7/ate
/sc Pumping 2. Quantity Pumped.
Gallons
3. Component: ❑ Ctic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe).-
4. Effluent Tee Filter presentIf yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company - -
7. L to here contents were disposed:
GLSD Lowell Waste Water
Signature of Hauler Date