HomeMy WebLinkAboutTitle V Inspection Report - 25 SUNSET ROCK ROAD 3/23/2016 Commonwealth of Massachusetts
City/Town of .
4� System Pumping.Record
Form 4
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 Information
1. System Location: Left/Right front of house, Left AjjEht rear of house�Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown State- Zipt
L�o -- Ll «--
Telephone Number + ,
e 1
B. Pumping record �.
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) 9-septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ No If yes,was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
lL'O,U9,t�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S: Lowell Waste Water
Sign a 9f HaulerU Date
0orm4.doc-06/03 System Pumping Record•Page 1 of 1