HomeMy WebLinkAboutTitle V Inspection Report - 31 JAY ROAD 9/20/2016 Commonwealth of Massachusetts ' IVE
City/Town of .
System P�umpin§-Record °° � ���
Form 4 wyc)VV^I Or,
lw�i���:,F�W��� �����(�����.��
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 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/ !ht front of hot , 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 � � G�✓ \ ',.���"" `°''°- °y� r°
City/Town State Zip Code
2. System Owner.
Name`
Address(if different from location)
cityfrown State Zip Code
Telephone Number '3
t
i
.B. Pumping record
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 ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6; System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson EhterEises Inc-
Company
7. Lo ti contents were disposed:
C L S: Lowell Waste Water
SignAtu a qf HauleV Date
t5f6rm4.doc•06103 System Pumping Record•Page 1 of 1