HomeMy WebLinkAboutSystem Pumping Record 2022 Commonwealth of Massachusetts
) =**- ,= i City/Town of W Yarmouth
___'° System Pumping Record
i
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, 8 Butler Ave
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:
lira, \
Michael Smith
Name
t Xt 1
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
10/03/2022 800.00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: Residential Septic Pumping (Residential Septic
❑ 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
Name Vehicle License Number
Waste Water Services, Inc. /Heritage Pumping
Company
7. Location where contents were disposed:
Plymouth WWTF
-- 10/03/2022
Sign ture o Date
Signature of Receiving Facility(or attach facility receipt) Date
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