HomeMy WebLinkAboutSystem Pumping Record 2022 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:
� I Buck Island Village
Name
xenon
A
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
09/09/2022 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 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 OG( 'L ( 2u2Z
Waste Water Services, Inc. /Heritage Pumping
Company HEALTH DEPT.
7. Location where contents were disposed:
New Bedford WWTP
09/09/2022
Signature olec: _ 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 Clty/Town of W Yarmouth
1.tr, __-_'"'- 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 2. System Owner:
Buck Island Village
Name
Own 11(
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
09/09/2022 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? X❑ Yes ❑ No
5. Observed condition of component pumped:
Good
6. System Pumped By:
Bob Brenton
Name Vehicle License Number
Dt_Waste Water Services, Inc. /Heritage Pumping F_
Company �' 0�� '
7. Location where contents were disposed: OCT 2 7 2022
New Bedford WWTP
HEALTH pEPT
- `' 09/09/2022 ----
Sign-ture o Heeler---._ 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 Ty/Town of
i, W Yarmouth HET
Ya
-''- ystem Pumping Record tH 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, 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:
Vrtab
Buck Island Village
Name
resin
/ 1
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
03/07/2022 6,000.00
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 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:
03/07/2022
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
*—° City/Town of W Yarmouth
ALM
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:
rab
Buck Island Village
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
05/25/2022 5,000.00
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:
05/25/2022
Sign ture o H. 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 VS` `. --J
Q-' -_ p/Town of W Yarmouth A"f 2 r; ?OR
___ Iantem Pumping Record
' _°-_' p. g HEALTH DEPT.
11--'. Form 4
ivgM�
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:
„reg
Buck Island Village
Name
MUM
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
03/07/2022 6,000.00
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:
03/07/2022
Sign ture o Hader-- Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1