HomeMy WebLinkAboutTitle V Inspection Report - 41 CEDAR LANE 9/19/2016 Commonwealth of Massachusetts RECEIVE
City/Town of
System Pumping-Record
i t i'C�:OTJ H A M:)C))DR
Form 4 HUj,'H I DE.HJF ,,MI��NI'
V•
DEP has provided this farm far use-by local Boards of Health. Other forms maybe*used, but the
information'must be substantially the same as that provided here. Before using.this farm, 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 hous Lekghhouse\ Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
6 C 9 � ' {� . .
CiWTown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown Stag � � _t''�e� .Z` �� '
Telephone Number .
i
.B. Pumping Record
1. Date of Pumping Late 2. Quantity Pumped: Gallons —`
3. Type-of system: ❑ Cesspool(s) pp°t c Tank ❑ Tight Tank ,.
❑ Other(describe): ,�, �--
4. Effluent Tee Filter present? [I Yep Icy N if yes, was it cleaned? ❑ Yes Q No,
5. Condition of st m:
6; System Pumped By:
Nell.Bateson - 1=5821
Name Vehicle License Number
Bateson Ehterprises Inc'
Company
7. Loca `=wh contents were disposed:
G
LS. Lowell Waste Water
SignAtufe I Haule Date
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