HomeMy WebLinkAboutPump Chamber - Septic Pumping Slip - 136 BRIDLE PATH 10/2/2023 Commonwealth of Massachusetts
f City/Town of
o
System Pumping Record
w Form 4 OCR
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: front back side rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location.
on the computer,
use only the tab
key to move your Address ^
cursor-do not I�n�O�r MA O -,rj�L15-
use the return key. City/Town State Zip Code
2. System Owner: 1
ray S 1�zve
Name
Address (if different from location)
MA
City/Town State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date
zG 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ �Tighlank �OG�reaseTrap
Other (describe): u
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
tx /\,-.`1
6. System Pumped By:
Dave Tiney Mass 5821 Mass 1AA95E
Name Vehicle NqlnspfNumber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
LSD
9
as�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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