HomeMy WebLinkAboutSystem Pumping Record 2023 Commonwealth of Massachusetts
►:=*_z, = City/Town of Yarmouth Port
'"'- 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, 960 Main St
use only the tab
key to move your Address
cursor-do not Yarmouth Port MA
use the return — —
key. City/Town State Zip Code
Oiriab 2. System Owner:
Oliver & Planck's
Name
rtaun
/
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
02/08/2023 6,000.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: GreaseDPT (Grease 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:
New Bedford WWTP
02/08/2023
Sign turd e o Hasler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
l=° i City/Town of Yarmouth Port
aL System Pumping Record
jForm 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, 960 Main St
use only the tab
key to move your Address
cursor-do not Yarmouth Port MA
use the return —
key. City/Town State Zip Code
2. System Owner:
tIrtab
N, Oliver & Planck's
Name
i
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
02/27/2023 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:
New Bedford WWTP
—�-f 02/27/2023
Sign turia e 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
1_**_= ,i City/Town Of Yarmouth Port
'"`- System Pumping Record
Toy—
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, 960 Main St
use only the tab
key to move your Address
cursor-do not Yarmouth Port MA
use the return City/Town State Zip Code
key.
2. System Owner:
14rua
Oliver & Planck's
Name
return
X\
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
07/15/2022 6,000.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: GreaseDPT (Grease Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? X❑ Yes E 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:
Wareham WPCF
07/15/2022
Sign ture o Hr \ Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1