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HomeMy WebLinkAboutTitle V Inspection Report - 29 JOHNNY CAKE STREET 9/21/2016 Commonwealth of Massachusetts Q Fri a ED City/Town of . Sy'tern Pumping-Record " " ` Form.4 .,,i;h�> �jrr ,k =;; HI" [.Ci.l& � 1't4�'�a1,..,if ©EP 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 e, rightode house Left/ Right side of building, Left/Right front of building, Left/Right rear of bul ding, Under deck Address s City/Town State Zip Code 2. System Owner. Name" Address(if different from location) City/Town Sta " i Code f Telephone Number �7 t .B. Pumping Rec©rd 1. Date of Pumping Date 2. Qu antity Pumped: Gallons y- 3. Type-of system: F] Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of System: 6: System Pumped By: Neil.Bateson - 1=5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location wh re contents were disposed: " Lowell Waste Water ' r /AD Slgn a qt Houle Date t5forrn4.doc•06/03 System Pumping Record•Page 1 of 1