HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 220 BOXFORD STREET 12/13/2021 local Board of Health to determine the form they use.The System Pum u
ping Record must be submitted
the local Board of Health or other approving authority.
A. Faci-tity Informnation
1. System Location: Left/Right front of house, Left/Right re use, Left/right side of house, Left
Right side of building, Left/Right front of building, Left ght rear f building, Under deck
on the computer, �6
use only the tab x
key to move your ss
cursor- not �� n /(,N'�L MA V
use the return r r�
key. City/Town State Zip Code
2. Sy m Owner: ,
1 / l�e
.,+' Name
Address(if different from location)
MA '
CitylTown State Zip Code
Telep ne 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,i1 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped. 56X/
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. LoQation where contents were disposed:
GLSD-x Lowell Waste Water
Signature of Hauler
Date