HomeMy WebLinkAboutTitle V Inspection Report - 46 RALEIGH TAVERN LANE 9/19/2016 Commonwealth of Massaohusefts
City/Town of REC NvED
System Pumping.Record �1.41
Form 4 TOV0i OF
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 Locado : L /Flight rout of house left I Right rear of house, Left/right side of house, Left/
Right side of b fdieft/Rig 'on of building, Left/Right rear of building, Under deck
Address
C`ityfrown State Zip Code
2. System owner.
Name'
Address(if different from location)
cityffown ' State _ Zip Cod
3
Telephone Number
l
B. Pumping Record
1. Date of Pumping �2. Qua tity Pum ped:
p Date Gallons 3. Type•of system: ❑ Cesspool(s) ank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 6 es ❑ No If yes,was it cleaned? 3--'6_s ❑ No,
5. Condition of System: t
6. System Pumped By:
} Nell.Batesbn . F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati ore contents-were disposed:
L S. Lowell Waste Water
F
Sign t e Haule Date
t5f0mf4.doc•06/03 System Pumping Record•page 1 of 1