HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 340 SUMMER STREET 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 Inforri�ation
I. System Location: Left/Right front of house, Left/Right rear of house, Left/. gieir
f house, Left !
Right sideof building, Left/Right front of building, Left/Right rear of building, deck
on the computer,
use only the tab —s/ -
3
L&e�-j `t�2
key to move your rity/lown
' B
cursor- et not9 MA (�Y use the return
key. State
Zp Code
2. Sy m Owner: �
Address(if different from location)
MA
City/Town State gode
n f
— '960 q
Telephone Number IF
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
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. L here contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date