HomeMy WebLinkAboutSystem Pumping Record 2023 Commonwealth of Massachusetts
IL-Aim_ i City/Town of S Yarmouth
'�'- System PumpingRecord
cf,"5"--- 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, 55 Long Pond Dr
use only the tab
key to move your Address
cursor-do not S Yarmouth MA
use the return
key. City/Town State Zip Code
2. System Owner:
„rr.. . Stop and Shop
Name
/ X N.
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
03/08/2023 8,500.00
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? ZI Yes ❑ No
5. Observed condition of component pumped:
Good
6. System Pumped By: c1
Bob Brenton 4 9�4) �10
Name Vehicle License Number F
Waste Water Services, Inc. /Heritage Pumping �' , r O
Company QA �I,
A:
7. Location where contents were disposed:
r'-- � 03/08/2023
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
':-* 1 City/Town of S Yarmouth
___'�'- 1 System Pumping Record
-� Form 4
i
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, 55 Long Pond Dr
use only the tab
key to move your Address
cursor-do not S Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
„r. N Stop and Shop
Name
i \
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
09/30/2022 8,500.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: GreaseDPT (Grease Disposal, Pumping and
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ 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 G31.l NGYED
Company
7. Location where contents were disposed: OCT 2 7 2022
Bar-Way Farm HEALTH DEPT
/ 09/30/2022
Sign lure 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 APR a Z02Z
ity/Town of S Yarmouth
S op
=='- 0 ystem Pumping Record HEALTH DEPT.
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, 55 Long Pond Dr
use only the tab
key to move your Address
cursor-do not S Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
Stop and Shop
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
03/10/2022 6,000.00
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? 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:
03/10/2022
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 U5~v
*— ity/Town of S Yarmouth APR ZQZZ
t-±-41:44-z-MA d s op
ystem Pumping Record HEALTH DEPT.
iv^M
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, 55 Long Pond Dr
use only the tab
key to move your Address
cursor-do not S Yarmouth MA
use the return City/Town State Zip Code
key.
®I2System Owner:
. Stop and Shop
Name
MILO
r
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
03/10/2022 2,500.00
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 ❑ 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:
03/10/2022
Sign turd e 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=-140=r** City/Town of S Yarmouth
'61- 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, 55 Long Pond Dr
use only the tab
key to move your Address
cursor-do not S Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
44 ' Stop and Shop
Name
rtmsn
i X\
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 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? 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
02/08/2023
Sign lure o-.fAce
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
tmol, City/Town of S Yarmouth
e 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, 55 Long Pond Dr
use only the tab
key to move your Address
cursor-do not S Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
VfritStop and Shop
Name
eem X\
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 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? ZI 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:
New Bedford WWTP
�._ 02/08/2023
Sign turd e 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 S 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, 55 Long Pond Dr
use only the tab
key to move your Address
cursor-do not S Yarmouth MA
use the return City/Town State Zip Code
key.
2. System Owner:
„frithStop and Shop
Name
MIN
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: 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
02/08/2023
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