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HomeMy WebLinkAboutSeptic Pumping Slip - 101 FOSTER STREET 5/24/2017Commonwealth of assachusett City/Town of y.te P mpan Record CIE • t.4 ?A '1017 TON N,cji, Ati "JIVER OEALTH DEPARTMENT DEP has provided this form for use=by local Boards Of Health. Other forms may 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. • A. Facility I iformation 1. System Location: Left / Right front of house, Left / Right rear of hous Right side of building, Left / Right front of building, Left / Right rear of buildin 2. System Owner: side of house' Le , Under Address(if different from location) City/Town ' Telephone Number P "It g Icor 1. Date of Pumping 3. Type•of system':0 ID Other (describe): 4. Effluent Tee Filter present? El Ye.p 5. Condition of System: t7 Date 2. Quantity pumped: Cesspool(s) Gallons eptic Tank 0 Tight Tank 6: System Pumped By: Neil Bateson ' Name Bateson Enterprises Inc Company 7. Locati niwhere contents were disposed: G. Lowell Waste Water If yes, was it cleaned? 0 Yes E3No F5821 Vehicle License Number t5form4.doo• Os/03 System Pumping Record • Page 1 of 1