HomeMy WebLinkAboutTitle V Inspection Report - 50 DEER MEADOW ROAD 9/17/2016 Commonwealth of Massachusetts
RECEIVED
= City/Town of .
System Pumping-Record fl � �
Form 4
.READ [HD I"I,l k._[HI
DEP has provided this form for use-by local Boards of Health. Other forms may ybe'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 Le Righ ron radio , Left 1 Right rear of house, Left.I right side of house, Left/
0 Right side of building, Left/Right ront of building, Left/Right rear of building, Under deck
Address
a? ��"<-
ciberown State Zip Code
2. System Owner.
Name*
Address(if different from location)
CitylTawn State- C,r�yt Co ;
t Telephone Number
r
.B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No,
" 5. Condition of System.
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio h contents-were disposed:
L S: Lowell Waste Water
sign We cf Hauie Date
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