HomeMy WebLinkAboutSeptic Pumping Slip - 300 FOSTER STREET 5/24/2017DEP has provided this form for use.by local Boards OlfrOHWral °11-th.IODLtheR:T:frMITEsRmay be 'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
Corn ' lonwealth of Massachusetts
City/Town of •
yetern Pu pin I ecord miv( 247011
For 4
. A. Facility Informatiop
1. System Location Righiont of house Left / Right rear of house, Left / right side of house, Left /
Right side of buil , Left / RigT • uildirig, Left / Right rear cif building, Under deck
Address
Soo
city/Town
2. System Owner:
kixti
Name.
Address (if different fiom tocatio )
4f,iiv\tk,
State
City/Town "
Zip Code
State
' (-to
Telephone Number
Zip Cede
B. P
g ec
7 C') 1 • Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Typeof system': D Cesspool(s) 0/eptic Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0/Yes rj No If yes, was it cleaned? DvYes 0 No,
" 5. Condition of System:
io 0 le d
6: System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
Company
7. where contents were disposed:
F5821
Vehicle License Number
Date
/ 7
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