HomeMy WebLinkAboutSystem Pumping Record 2023 Commonwealth of Massachusetts
rCit /Town of S Yarmouth
Y 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, 474 Station Ave
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:
„fr. Stop and Shop
Xf•
Name
ream
i
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
02/14/2023 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 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
02/14/2023
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 s .
P =- — ity/Town of S Yarmouth / 0 'O,
-_-;_=f d S op
=`-"'- ystem Pumping Record
== 11_ 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, 474 Station Ave
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:
4ea , Stop and Shop
Name
rerun
/
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
03/02/2022 6,000.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: GreaseDPT(Grease Disposal, Pumping and Transportation Services)
E 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:
03/02/2022
Sign ture o H. rler----_... Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts JUL
L i 8 2022
City/Town of S Yarmouth
System 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, 474 Station Ave
use only the tab
key to move your Address
cursor-donot S Yarmouth MA
use the return — —
key. City/Town State Zip Code
2. System Owner:
t Stop and Shop
Name
return
I
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
06/14/2022 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? 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:
Wareham WPCF
06/14/2022
Sign ture o H a}er—---_ 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 S Yarmouth
__"= System Pumping Record
�1— 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, 474 Station Ave
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:
4 . Stop and Shop
Name
remm
i X•
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
09/30/2022 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 El No If yes, was it cleaned? El 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 G`SC==IgEUVIM
7. Location where contents were disposed:
Cranston WPCF OCT 27 2022
__---_ 09/30/2022 HEALTH DEPT.
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
► -E— p= i City/Town of S Yarmouth
k.Mill'= 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, 474 Station Ave
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:
virth , Stop and Shop
Name
i ORR X' Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
03/20/2023 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? ZI Yes ❑ No
5. Observed condition of component pumped:
Good
6. System Pumped By:
Bob Brenton V
Name Vehicle License Number ,p 1,010
Waste Water Services, Inc. /Heritage Pumping J 1.
Company (may &, 4
to
7. Location where contents were disposed: ,O cry
.O.,A.
/____ 03/20/2023
Signature o H; ;e--- Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1