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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 WINDKIST FARM ROAD 12/13/2021 local Board of Health to determine the form they use. The System Pumping Record must be submitted ft the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left Right side of building, Left/Right front of building, Left/Tght rear of building, Under deck on the computer, use only the tab key to move your Un1j, cursor- et not ,d /� MAuse the return ,>'L/� /a key. r ity/I own State Zip Code 2. System Owner: , .� tc C' Name rmm dr .. Address(if different from location) MA ' CitylTown State � � © -'ZZ60� Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: A;&o Gallons 3. Component: ❑ Cesspool(s) Se tic Tank Tight Tank El Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o 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. Loca i n where contents were disposed: LSD Lowell Waste Water Signature of Hauler Date