HomeMy WebLinkAboutSystem Pumping Record 2023 Commonwealth of Massachusetts
*— City/Town of W Yarmouth
System Pumping Record
s. �`•o 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 y ,JUN 22 Z023
filling out forms 1. System Location:
on the computer, 481 Buck Island Rd
use only the tab HEALTH DEPT.
key to move your Address
cursor-do not W Yarmouth MA
use the return City/Town State Zip Code
key.
tiof,
2. System Owner:
Buck Island Village
Name
X•
(enm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
05/04/2023 5,000.00
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:
05/04/2023
Sig 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
'- _ Cit /Town of W Yarmouth
• -,...zr` 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: JUN 2 2 2023
on the computer, 481 Buck Island Rd
use only the tab
key to move your Address HEALTH DEPT.
cursor-do not W Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
vir., . Buck Island Village
Name
reom
J X\
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
05/04/2023 5,000.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: SepticDPT (Septic Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes 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:
/ure o� 05/04/2023
Sig tH el - 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 W Yarmouth
►- SUN 22 2023 i
System Pumping Record
=� = Form 4 HEALT DEPr
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, 481 Buck Island Rd
use only the tab
key to move your Address
cursor-do not W Yarmouth MA
use the return
key. City/Town State Zip Code
2. System Owner:
Buck Island Village
Name
ream
i e
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
05/04/2023 3,500.00
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: SepticDPT (Septic Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? 0 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:
05/04/2023
Sig Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
Z----47.4. i Clt /TOWn Of W Yarmouth
Y
=itff 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, 481 Buck Island Rd
use only the tab
key to move your Address
cursor-do not W Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
„r, , Buck Island Village
X Name
2mm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
02/28/2023 5,000.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: SepticDPT (Septic Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes El 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:
Plymouth WWTF
02/28/2023
Sign Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
Iliii—i=r City/Town of W 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, 481 Buck Island Rd
use only the tab
key to move your Address
cursor-do not W Yarmouth MA
use the return City/Town State Zip Code
key.
4 1 2. System Owner:
1 Buck Island Village
Name
I X\
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
02/28/2023 5,000.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: SepticDPT (Septic Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes E No If yes, was it cleaned? ZI 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:
Plymouth WWTF
02/28/2023
Sign lure o Hamer— 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 W Yarmouth
-R`'I System Pumping Record
c 22117
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, 481 Buck Island Rd
use only the tab
key to move your Address
cursor-do not W Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
ii(no
Buck Island Village
Name
MUM
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
02/28/2023 5,000.00
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? 1 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:
Plymouth WWTF
02/28/2023
Sign ture 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
- City/Town of W Yarmouth
'"�. -apiii_— 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, 481 Buck Island Rd
use only the tab
key to move your Address
cursor-do not W Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
,,,fr.,
Buck Island Village
Name
i X\
Bnm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
02/28/2023 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 E 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:
Plymouth WWTF
02/28/2023
Sign ture o Hamer---- 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 City/Town of W Yarmouth
�'"'- System Pumping Record
i.s
d
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, 481 Buck Island Rd
use only the tab
key to move your Address
cursor-do not W Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
14r2o
N. Buck Island Village
Name
rerun
I X\
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
02/28/2023 5,000.00
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 ❑ 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:
Plymouth WWTF
/reo 02/28/2023
Sign tu 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
City/Town of W 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, 481 Buck Island Rd
use only the tab
key to move your Address
cursor-do not W Yarmouth MA
use the return
City/Town State Zip Code
key.
2. System Owner:
Vre
Buck Island Village
Name
i X\
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
02/28/2023 5,000.00
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:
Plymouth WWTF
02/28/2023
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
Commonwealth of Massachusetts
City/Town of W Yarmouth
'"1- 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, 481 Buck Island Rd
use only the tab
key to move your Address
cursor-do not W Yarmouth MA
use the return City/Town State Tip Code
key.
2. System Owner:
„tr.5Buck Island Village
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 02/07/2023 2 QuantityPumped: 6,000.00
Date um p 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:
Plymouth WWTF
02/07/2023
Sign ture o Ha 4er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
.=**zpt City/Town of W Yarmouth
=11I- 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, 481 Buck Island Rd
use only the tab
key to move your Address
cursor-do not W Yarmouth MA
use the return City/Town State Zip Code
key.
th(f'6
2. System Owner:
Buck Island Village
Name
/41"X
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
02/07/2023 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? El 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:
Plymouth WWTF
•
02/07/2023
Sign ture o Haaler— Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1