HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 JERAD PLACE 12/13/2021 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 Informiation
1. System Location: Left/ �ht from use, Left/Right rear of house, Left/right side of house, Left
Right 'de of building, efRigh frtin f building, Left/Right rear of building, Under deck
on the computer, v % &�4
use only the tab
key to move your Address
cursor-do not
use the return cy?— MA
key. City1rown State
Zip Code
2. Sys m Owner: ,
`e FO G
Name
Address(if different from location)
MA '
City/Town State ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 0 PIn9 . Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s)
*Septic Tank El Tight Tank El 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
' " W
Bateson Enterprises, Inc.
Company
7. Loc - n where contents were disposed:
LS Lowell Waste Water
Signature of Hauler Date J
