HomeMy WebLinkAboutSystem Pumping Record 2022 Commonwealth of Massachusetts
►.="= c City/Town of South Yarmouth
k____= 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, 1105 MA-28
use only the tab
key to move your Address
cursor-do not South Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
Piccadilly Café &
Name
rerun
/ X\
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
10/31/2022 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 ❑ 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
10/31/2022
Sign ture o H 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 , _ �f, a�
3 V. 2 L1---=-=-'7,11, Clty/Town of South Yarmouth ` �,OV 2
___ _ 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, 1105 MA-28
use only the tab
key to move your Address
cursor-do not South Yarmouth MA
use the return City/Town State Zip Code
key.
4 2. System Owner:
Piccadilly Café &
Name
ream
/ XN.
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
10/31/2022 3,000.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: GreaseDPT (Grease Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes E 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
10/31/2022
Sign ture o Hadler----__ Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1