HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 BEAVER BROOK ROAD 12/13/2021 --...o._.._ ._....,.......... ..,., yuu
local Board of Health to determine the form they use.The System Pumping Record must be submitted t(
the local Board of Health or other approving authority.
A. Facility tnforri�ation
1. System Location: Left/Right front of house, Left/Right Wt
f se, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/ eta of building, Under deck
on the computer, m /r
use only the tab
key to move your Add re
cursor-do not
use the return o v MA l �j
key. ity/Town State Zip Code
2. Sy2tem owner ,
J Name
Address(if different from location)
MA
City/Town State
Code
I elephone Number
B. Pumping Record
1. Date of Pumping g Date �✓ 2- Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ If 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. Location where contents were disposed:
GLS Lowell Waste Water
Signature of Hauler Date