65 Title 5 Pumping Records 2012, 2014 Commonwealth of Massachusetts
Q City/Town of NORTHAMPTON
y System Pumping Record
Form 4
Important:
When filling
out forms on
the computer,
use only the
tab key to
move your
cursor-do
not use the
return key
far
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
1. System Location:
Address
NORTHAMPTON
City/Town
2. System Owner:
JOSEPH KELLY
Name
MASS
State
01060
Zip Code
Address(if different from location)
State
City/Town State
531 9862
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping MAY 15, 2012 2. Quantity Pumped: 1500
Date Gallons
3. Component: II I Cesspool(s) ® Septic Tank ❑ Tight Tank Grease Trap
❑ Other
(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:
FREDDIE
Name
CLEAN SEPTICS INC
Company
7. Location where contents were disposed:
BONDI'S ISLAND
Signature of Hauler
t5form4 doe-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
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 15351.
A. Facility Information
Important:
When filling 1. System Location:
out forms on
the computer,
use only the Address
tab key to NORTHAMPTON /FLORENCE MASS.
vor-do City/Town State
not use the
return key 2. System Owner:
JOSEPH KELLEY
m
Name
1 Address(if different from location)
EIaQRENCE
City/Town State
531 9862
Telephone Number
01060
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping
3. Component:
❑ Other
(describe):
4. Effluent Tee Filter present? ❑ Yes ® No If yes,was it cleaned?
SEPTMBR 9,
2. Quantity Pumped:
2014
Carpool(s) ® Septic Tank ❑ Tight Tank
1500
Gallons
❑ Grease Trap
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 INDIAN ORCHARD
Yes No
ORANGE/SILVER MACK
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