HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 SPRUCE STREET 12/13/2021 local Board of Health to determine the form they use.The.System rVU
ystem Pumping Record must be submitted
the local Board of Health or other approving authority.
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A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right ide of buiidin Left/Right front of builds ' , Left/Right rear of building, Under deck
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key to move your Ad re
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use the return � MA
key. ity/Town State
Zip Code
2. System Owner: ,
Name —- —
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Address(if different from location)
_ MA '
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
p g Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YjNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componentd:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. where contents were disposed:
GLSD Lowell Waste Water
Signature of Hauler Date