HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 FARNUM STREET 12/13/2021 YULS
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 Information
1. System Location: Left/Right front of house, Left/ rear of sly, Left/right side of house, Left
Right side of buildir�, Left/Right front of building, Leff)/Right rear f building, Under deck
on the computer,
use only the tab
key to move your Add sscur udo
se
the
return s a &
use the return
key. City/I own State
Zip Code
2_ Sys MOW
er: ,,, l ,
t ame
Address(if different from location)
_ MA
CitylTown State Zip Code
-7
9r(aad
/
Telephone Number
B. Pumping Record
1. Date
of Pumping Date 2. Quantity Pumped.
Gallons
3. Component:p ❑ Cesspool(s) . Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No 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:
GLSD Lowell Waste Water
a
Signature of Hauler Date