HomeMy WebLinkAboutTitle V Inspection Report - 10 CAMPBELL ROAD 9/17/2016 Commonwealth of Massachusetts
City/Town of .
System Pumping-Record
' Form 4 • p r.�; �: i VIr,i'�I-�� ,,, ;`n f�
DEP has provided this form for use�by local Boards of Health. Other farms may be used, but the
lnformation'must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the farm 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 housCiting,rig h s� ica of i.�ous , Left/
Right side of building, Left/Right front of building, Left/Right rear cif Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State u 1 Zip de
b
Telephone Number �+
.B. Pumping Wkocord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [D o If yes, was it cleaned? ❑ Yes Q No,
5. Condition of System Ala 6. System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents-were disposed:
teHaulVe Lowell Waste Water Sig Date d�
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