HomeMy WebLinkAboutTitle V Inspection Report - 211 CANDLESTICK ROAD 8/19/2015 Commonwealth of Massachusetts EC-rodVED
City/Town of
A G' 15
s *tem Pumping-Record U
YS ��OF�IHAO,MOVER
Form 4 OF 1�
Dl_f-'N I ML VF
DEP has provided this form'for usez by local Boards of Health. Other forms may be'used, but the
information-must be substantially the tame 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/Right front of house, Left fRlht rggirof-house), Left/right side of house, Left I
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address
c,
Cityfrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown stat H 2) Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: ❑ ' Cesspool(s) 0-8-6/ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ❑ Yes F-1 No,
5. Condition of System:
6.. System Pumped By:
Neil.Batesbn F5821
_Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatir��hqre contents were disposed:
/GLS'.b Lowell Waste Water
LX0A 4r
Sign cf H-aulev Date
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