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HomeMy WebLinkAboutSystem Pumping Record 2022 Commonwealth of Massachusetts ►:=* i 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, 183 Main Street use only the tab key to move your Address cursor-donot West Yarmouth MA use the return City/Town State Zip Code key. 2. System Owner: m , The Cove at Name ream i Xs. Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 09/22/2022 3,500.00 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 i-` QVI. D 6. System Pumped By: Ott 2 7 to 71 Bob Brenton ICALTN ° VT. Name Vehicle License Number Waste Water Services, Inc. /Heritage Pumping Company 7. Location where contents were disposed: Wareham WPCF 09/22/2022 Signature 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 �.=**= _ City/Town of West Yarmouth k,__el 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, 183 Main Street 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: „tr., , The Cove at Name Ben i X\ Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 10/31/2022 8,500.00 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: SepticDPT (Septic Disposal, Pumping and ❑ Other(describe): 4. Effluent Tee Filter present? XI Yes El 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 "> - 10/31/2022 Sign ture o H�dler 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 t WM01 System Pumping Record V - 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, 183 Main Street 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: vrabThe Cove at Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 10/31/2022 8,500.00 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: SepticDPT (Septic Disposal, Pumping and ❑ Other(describe): 4. Effluent Tee Filter present? IX] 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 10/31/2022 Sign lure o FIB--- 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 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, 183 Main Street 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: „tr. The Cove at Name fun r 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: SepticDPT (Septic Disposal, Pumping and ❑ Other(describe): 4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? E 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 10/31/2022 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 ►:=*-° , 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, 183 Main Street 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: The Cove at � X Name n 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: SepticDPT (Septic Disposal, Pumping and ❑ Other(describe): 4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? 111 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 10/31/2022 Sign ture o Nadler-- 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--,1:161, 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, 183 Main Street 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: V rt a b \ The Cove at Name 1 mum X Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 10/31/2022 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? 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: New Bedford WWTP �- 10/31/2022 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 ':='*=, = i City/Town of West Yarmouth k._=O System Pumping Record 1yForm 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, 183 Main Street 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: The Cove at X Name ream i • Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 10/31/2022 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? 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: New Bedford WWTP 10/31/2022 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 Cit own 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, 183 Main Street 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: I The Cove at Yarmouth Name ram I Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 05/12/2022 5,500.00 1. Date of Pumping pate 2. Quantity Pumped: Gallons 3. Component: SepticDPT (Septic Disposal, Pumping and Transportation Services) ❑ 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: 05/12/2022 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 Qr—*_t, 4 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, 183 Main Street 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: '®I The Cove at Yarmouth Name rerun i Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Pumping05/12/2022 5,500.00 Date of Date 2. Quantity Pumped: Gallons 3. Component: SepticDPT (Septic Disposal, Pumping and Transportation Services) ❑ 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: 05/12/2022 Sign turd 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 _ 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, 183 Main Street 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: The Cove at Yarmouth X Name main! � Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 05/12/2022 5,500.00 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: SepticDPT(Septic Disposal, Pumping and Transportation Services) ❑ Other(describe): 4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? 0 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: 05/12/2022 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 " West Yarmouth I=110= c City/Town of �11-1--- System Pumping Record-f Form 4 j 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, 183 Main Street 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: Vtrao The Cove at Yarmouth Name stun rX Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 05/12/2022 8,500.00 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: SepticDPT (Septic Disposal, Pumping and Transportation Services) ❑ Other(describe): 4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? 11 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: 05/12/2022 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 -* = West Yarmouth = = I City/Town of __411-L 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, 183 Main Street 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: The Cove at Yarmouth Name 2run / X v Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 05/13/2022 3,500.00 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: GreaseDPT(Grease Disposal, Pumping and Transportation Services) ❑ 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: (-:'— 05/13/2022 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 =_ y 1 City/Town of West Yarmouth kT-7'"'== 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, 183 Main Street use only the tab key to move your Address cursor-do not West Yarmouth MA use the return City/Town State Zip Code key. f 2. System Owner: The Cove at Yarmouth Name e X\ Isom Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 05/31/2022 8,500.00 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: SepticDPT(Septic Disposal, Pumping and Transportation Services) ❑ 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: e—: — 05/31/2022 Sign ture o Nadler— Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1