HomeMy WebLinkAboutTitle V Inspection Report - 60 TIFFANY LANE 9/17/2016 Commonwealth of Massachusetts °" ° � "
City/Town of
s ,
S' tem Pumping.Record �d�a �����:� :�r�����i E���r
Form 4
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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/ hit front of ususe�Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CRY/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
cityrrown State zip Code ;
,
Telephone Number
d
.B. Puimping 119cord
1. Date of Pumping Date 2. Quantity Pumped: Geltans r�'
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [D"N�o If yes,was it cleaned? ❑ Yes ❑ No
' 5. Condition of Sys em:
6. System Pumped By:
Nell.Meson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
S: Lowell Waste Water
Sign a I Haule Date
t5f6rm4.doo-06/03 System Pumping Record•Page 1 of 1