HomeMy WebLinkAboutSystem Pumping Record 2023 Commonwealth of Massachusetts
City/Town of West Yarmouth
System Pumping Record
Form 4
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 579 Buck Island Rd
use only the tab
key to move your Address
cursor-do not West Yarmouth MA
use the return
key. City/Town State Zip Code
2. System Owner:
Mayflower Place
Name
inn XN\
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
01/09/2023 2,500.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: SepticDPT (Septic Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? X❑ Yes ❑ No
5. Observed condition of component pumped:
Good
6. System Pumped By:
Bob Brenton
Name Vehicle License Number
Waste Water Services, Inc. /Heritage Pumping
Company
7. Location where contents were disposed:
Cranston WPCF
01/09/2023
Signature o Hfer- Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
►.-* , = i City/TOwn Of West Yarmouth
c '— System Pumping Record rill=j---- '
-T 1 Form 4
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 579 Buck Island Rd
use only the tab
key to move your Address
cursor-do not West Yarmouth _ MA
use the return City/Town State Zip Code
key.
4 2. System Owner:
♦ Mayflower Place
Name
/MUM X
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
01/09/2023 5,500.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: SepticDPT (Septic Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes El No If yes, was it cleaned? X❑ Yes El No
5. Observed condition of component pumped:
Good
6. System Pumped By:
Bob Brenton
Name Vehicle License Number
Waste Water Services, Inc. /Heritage Pumping
Company
7. Location where contents were disposed:
Cranston WPCF
- / 01/09/2023
Sign lure o H Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
'.= _ i City/Town/Town of West Yarmouth
-�,►— , System Pumping Record
Form 4
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 579 Buck Island Rd
use only the tab
key to move your Address
cursor-do not West Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
Mayflower Place
Name
MUM
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 01/09/2023 2. Quantity Pumped: 5 Mons 0
DateGallons
3. Component: SepticDPT (Septic Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? X❑ Yes ❑ No
5. Observed condition of component pumped:
Good
6. System Pumped By:
Bob Brenton
Name Vehicle License Number
Waste Water Services, Inc. /Heritage Pumping
Company
7. Location where contents were disposed:
Cranston WPCF
01/09/2023
Sign ture o HIcr — Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
1-=-71111=r City/Town of West Yarmouth
W- System Pumping Record
Form 4
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 579 Buck Island Rd
use only the tab
key to move your Address
cursor-do not West Yarmouth MA
use the return
key. City/Town State Zip Code
2. System Owner:
Mayflower Place
Name
MEI X
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
01/09/2023 5,500.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: SepticDPT (Septic Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? X❑ Yes ❑ No
5. Observed condition of component pumped:
Good
6. System Pumped By:
Bob Brenton
Name Vehicle License Number
Waste Water Services, Inc. /Heritage Pumping
Company
7. Location where contents were disposed:
Cranston WPCF
01/09/2023
Sign ture o Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
1===1± Cit /Town of West Yarmouth
'— System Pumping Record
Form 4
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 579 Buck Island Rd
use only the tab
key to move your Address
cursor-do not West Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
r�111
Mayflower Place
Name
ieom
i
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
01/09/2023 6,000.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: SepticDPT (Septic Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? X❑ Yes ❑ No
5. Observed condition of component pumped:
Good
6. System Pumped By:
Bob Brenton
Name Vehicle License Number
Waste Water Services, Inc. /Heritage Pumping
Company
7. Location where contents were disposed:
Cranston WPCF
01/09/2023
Sign ture o H n�ler— Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of West Yarmouth
System Pumping Record
Form 4
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 579 Buck Island Rd
use only the tab
key to move your Address
cursor-do not West Yarmouth MA
use the return
key. City/Town State Zip Code
2. System Owner:
Mayflower Place
Name
ream
/ AP N.
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
01/09/2023 5,500.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. component: SepticDPT (Septic Disposal, Pumping and
E Other(describe):
4. Effluent Tee Filter present? ® Yes E No If yes, was it cleaned? X❑ Yes ❑ No
5. Observed condition of component pumped:
Good L�SLL /L
FEB 2'1 2023
6. System Pumped By:
Bob Brenton HEALTH DEPT.
Name Vehicle License Number
Waste Water Services, Inc. /Heritage Pumping
Company
7. Location where contents were disposed:
Cranston WPCF
01/09/2023
Sign er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1