HomeMy WebLinkAbout- Septic Pumping Slip - 365 CANDLESTICK ROAD 12/13/2021 local Board of Health to determine the form they use. The System Pumping Record must be submitted u
the local Board of Health or other approving authority.
A. Facility Inforriation
1. System Location: Left/Right front of house, Left/ ear of house, Left/right side of house, Left �
Right side ar_of building, Left/Right front of buildiri , eft ght ebuilding, Under deck
on the computer,
use only the tab
key to move your Addless
cur
do
use the
return �(
use the return s" `t MA �
key. City/I own State
Zip Code
2_ Sy Owner: �
y Name
/esm cr`'
Address(if different from location)
MA '
City/Town State � p Codes
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ 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
Signature of Hauler Date