HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 970 JOHNSON STREET 12/13/2021 local Board of Health to determine the forrh they use.The.System Pumping Record must be submitted t(
the local Board of Health or other approving authority.
A. Facility Inforri�ation
1. System Location: Left/Ri h#fron . f douse Left/Right rear of house,9 Left/right side of house, Left
Right side of building, Left fight front of building, Left/Right rear of building, Under deck
on the computer, i
1
use only the tab � _ rV\ l q o � s� Cat n
key to move your dd ess
cursor-do not �/7r�� y��( -�
use the return / (� J ` MA
key. City/Town State Zip Code
2. S stem Ow per: ,
3i I I
Name
Address(if different from location)
MA '
City/Town Stat
7SYe� Zip Cod
0
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
/ G
ate P Gallons
3. Component: ❑ Cesspool(s) e tic Tank
Tight Tank El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes r a No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C/
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. L ab n where contents were disposed:
GLSD Lowell Waste Water J
Signature 0
f Hauler Date_L
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