79 Pumping Record 2012 Commonwealth of Massachusetts
!a City/Town of NORTHAMPTON
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.
Important:
When filling
out forms on
the computer,
e only the
tab key to
move your
cursor-do
not use the
return key.
A. Facility Information
1. System Location:
AMMIMant
Address
NORTHAMPTON
City/Town
2. System Owner:
HOME CITY HOUSING
Name
MASS
State
01060
Zip Code
Address(if different from location)
State -
City/Town State Zip Code
CHRIS 2653111
Telephone Number
B. Pumping Record
MAY 15, 2012 1000
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
ID D 3. Component: Cesspool(s) Septic Tank Tight Tank n Grease Trap
® Other clean/maintain pit ensile w/contractor
(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? ❑ Yes P No
5. Observed condition of component pumped:
6. System Pumped By:
FREDDIE
Name
_ CLEAN SEPTICS INC
Company
7. Location where contents were disposed:
BONDI'S ISLAND
t5form4 doc•11/12
SILVER/YELLOW HAULER L66-868
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
J
Commonwealth of Massachusetts V City/Town of NORTHAMPTON
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 1. System Location:
out forms on SORMinill
the computer,
use only the Address
tab key to NORTHAMPTON
move your City/Town cursor-do
not us 2. System Owner:
return return key key
HOME CITY HOUSING
Name
MASS
State
01060
Zip Code
Address Of different from location)
State
City/Town State Zip Code
Telephone Number
B. Pumping Record
AUGUST 31, 1500
1. Date of Pumping 2012 2. Quantity Pumped: Gallons
❑ Date 1
3. Component: Cesspool(s) Septic Tank ❑ Tight Tank n Grease Trap
IA Other CLEANED /MAINTAINED PIT, ONSITE W/CONTRACTOR
(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was It cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
LUIS
Name
CLEAN SEPTICS INC
Company
7. Location where contents were disposed:
BONDI'S ISLAND
Signature of Hauler
t5form4.doc•11/12
SILVER/YELLOW HAULER L66-868
Vehicle License Number
Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
c City/Town of NORTHAMPTON
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.
Important:
When filling
out forms on
the computer,
use only the
tab key to
ce your
ursor-do
not use the
return key.
A. Facility Information
1. System Location:
Address
NORTHAMPTON
City/Town
2. System Owner:
HOME CITY HOUSING
Name
MASS
State
01060
Zip Code
Address(if different from location)
State
City/Town State Zip Code
Telephone Number
B. Pumping Record
MAY 22 2013 1000
1. Date of Pumping
Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank 0 Tight Tank (] Grease Trap
® Other PUMP CHAMBER MAINTENANCE
(describe):
4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
LUIS
Name
CLEAN SEPTICS INC
Company
7. Location where contents were disposed:
BONDI'S ISLAND
SILVER/YELLOW HAULER L66-868
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4 doc•11/12
System Pumping Record•Page 1 of 1
J