HomeMy WebLinkAboutTitle V Inspection Report - 280 CANDLESTICK ROAD 9/21/2016 Commonwealth of Massachusetts r, �°��Y�
City/Town of .
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/Right rear of house, Left/right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
cityrrown State - Zip Code
2. System Owner.
Name'
Address(if different from location)
City/7'own Stater� �
Zip d
Telephone Number
.B. Pumping Jkecord
1. date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type•of system: L] Cesspool(s) Lj Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p ❑ Yes 0-1Co � if yes, was it cleaned? ❑ Yes ❑ Na,
5. Condition of Syste
6. System Pumped By:
Neil.Bates ri F5821
Name Vehicle License Number
Bateson Ehterprises Inc
Company
7. Lon ere contents were disposed:
7Lowell Waste Water
Sign a HiiuleV Date
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