776 Title 5 Pumping Records 2012-2015 Commonwealth of Massachusetts
City/Town of
Syysienm 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 3W CMR 15.351.
A. Facility Information
1. System Location:
t +
Address
•
LL `t"IiL-i,21 l4 � .C_ �l _... _ MA.
Cdtynr vn t State
2. System Owner:
7)et ! 1 I < LLfl11�• C C.:
Name
Address Q(different from location)
MA
City/Town State
Telephone Number
Zip Code
Zip Code
. Purn` ng Record
5 1. Date of Pumping p �2� / `�-- 2. Quantity Pumped: uons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
L I Other(describe): - -
4. Effluent Tee Filter present? ❑ Yes X„,No If yes, was it cleaned? ❑ Yes
6. System Pumped By:
Michael Beausoleil
Name Vehicle License Number
Bostley Sanitary Service Inc.y'
Compan _ . .. .
7. Location where contents were disposed:
Erving Waste Water Treatment Plant
5. Condition of System:
Okay_.____._
Signature of Hauler-
Signature of Receiving Facikty
Date
Date
t5form4.der°03/06 System Pumping Record•Page 011
Commonwealth of Massachusetts
City/Town of
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
1. System Location:
1I, \'N .') C AThce-Q--- -
Address
NJ O i(-H`N avh rrkn in MA tho ( q C')
Citylrown C _ State Zip Code
2. System Owner:
Sand\r't
Name
Address(if different from location)
City/Town
MA
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
}/- -9/12 Quantity Pumped:
500
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present'? ❑ Yes yf' No If yes, was it cleaned? ❑ Yes 1, No
5. Condition of System:
Okay
6. System Pumped By
Michael Beausoleil
Name
Bostley Sanitary Service Inc.
Company
7. Location where contents were disposed:
Ervinq Waste Water Treatment Plant
rm4doc•03/06
Vehicle License Number
Signature o(H3uf2ip "1
Signature of Receiving Facility
7/oZ//2
Date //
Date
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
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
1. System Location:
\ A
! Address
ECG
CI y &Cn 1 t\cL9 hD t�
2. System Owner:
Name 7 1dy
MA DIO(PQ
State Zip code
Address Of different from location)
CityFrown
MA
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
2. Quantity Pumped:
/, 500
Ions
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe).
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes No
5. Condition of System:
Okay
6. System Pumped By:
Michael Beausoleil
Name Vehicle License Number
Bostley Sanitary Service Inc.
Company
7. Location where contents were disposed.
Ervin Waste Water Treatment Plant
a «
Signature of H ufB !
Signature of Receiving Facility
m4.doc•03/06
Date
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
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
1. System Location:
Address v"
_ v 1`�e t rr/4,1(7/C K/ MA
City/Town State
2. System Owner:
±/ /)t / .S
Name
Zip Code
Address(if different from location)
City/Town
MA
State
Zip Code
Telephone Number
B. Pumping Record
- / � e / S d b
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) N&eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Okay
6. System Pumped By:
Michael Beausoleil
Name
Bostley Sanitary Service Inc.
Company
7. Location where contents were disposed:
Mon, Waste Water Treatment Plant
form4.doc•03106
Vehicle License Number
Signature of H.u�' ` � • Date
Signature of Receiving Facility Date
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
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
1. System Location:
Address — - - —�
4
City/Town
2. System Owner.
Name
Address(If different from location)
S—C
MA
State
MA
GitylCity/Town State
Telephone Number
OINPO
Zip Code
Zip Code
B. Pumping Record /-
- 2. Quantity Pumped:
1. Date of Pumping Date
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ,Z No If yes, was it cleaned? ❑ Yes 7 No
5. Condition of System:
Okay
/yr
Gallons
Grease Trap
6. System Pumped By:
Michael Beausoleil__
Name
Bostley Sanitary Service Inc.
Company
7. Location where contents were disposed:
Erving Waste Water Treatment Plant ._
t6form4.doc•03/06
Signature of Hain ' '
Signature of Receiving Facility
Vehicle License Number
Date
Date
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
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
1. System Location:
I l VCC-e-V
Address
Cityrrnwn
2. System Owner:
Name
MA
State
0KoCQo
Zip Code
Address Of different from location)
City/Town
MA
State
Zip Code
Telephone Number
B. Pumping Record 7
1. Date of Pumping Date 2 —I —1�L, Quantity Pumped: �O C)
a%ns
3. Type of system: ❑ Cesspool(s) Ipeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ to If yes, was it cleaned? ❑ Yes I 10
5. Condition of System: l"
Okay
6. System Pumped By:
Michael Beausoleil
Name
Bostley Sanitary Service Inc.
Company
7. Location where contents were disposed:
Erving Waste Water Treatment Plant
Vehicle License Number
1.
Signature of H3uMr-
Date
£ -L `-f -(2
Signature of Receiving Facility
Date
t5form4.doc 03/08 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System lPump np Record
Form 6
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 CNIR 15.351.
��. Facatlat:yy lfixormatuon
System Location:
ITOkd K
Address
MA
City, o State Zia Code
2. System Owner
Name
Address(if different from location)
City/Town
MA
State
Telephone Number
Zip Code
B. Pumphig G3ecovrdl
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspooi(s) E. Septic Tank El Tight Tank ] Grease Trap
] Other (describe): - - — —
Effluent Tee Finer present? ❑ Yes Ilh Mo If yes, was it cleaned? ] Yes [No
5. Condition of System:
Okay
e. System Pumped By:
Michael Beausoleil
Name
Bostley Sanitary Service Inc.
Company
Z Location where contents were disposed
Erving Waste Water Treatment Plant
Signature of Hauler
Signature of Receiving Fci!ity
t51orm4 tl; 03/06
Vehicle License Number
Date
Date
System Pumping Record•Raga of 1
Commonwealth of Massachusetts
City/Town of
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
1. Syst�n Location:
1`i
MA
State
2. System
Owner:
Name n ei r yv e c4t c v
&x-
Zip Code
Address(if different from location)
City/Town
MA
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date
S—I rr2_/ 2. Quantity Pumped: ca on^ s
3. Type of system: 111 Cesspool(s)Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes Or No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Okay
6, System Pumped By:
Michael Beausoleil
Name
Bostley Sanitary Service Inc.
Company
7. Location where contents were disposed:
•irywg Waste Water Treatment Plant
Vehicle License Number
Olotainoe
Signature f li.0 ,. Date
Signature of Receiving Facility
Date
ifarm4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
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
1. System Location:
Ski ° K,v1
Address
AlOn ]AWfeica�
City/Town
2. System Owner:
Jana c
Name
MA
e
01U(oO
Zip Code
Address Of different from location)
Cityrtawn
MA
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date/a-b_ 'a 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) IK Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes %No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Okay
5. System Pumped By:
Michael Beausoleil
Name
Bostley Sanitary Service Inc.
Company
7. Location where contents were disposed:
—Ewing-Waste Water Treatment Plant
Vehicle license Number
( ear •
Signature of H
la - is-P-
Date
Signature of Receiving Facility
Date
5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System stem Pum in
�'� Y 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.
'onset:When
rg out forms
the computer.
only the tab
to move your
sor-do not
the return
A. Facility Information
1 System Location:
Address
City/Tow^.
2. System Owner:
6afl`t PC. ,1
Name
1_ .i13'3 11110 ACC
Address(if different from location)
City/Town
MA
State
"Th t 0 L,.':'.
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
/2012. 2. Quantity Pumped. Gallons
EnD
3 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe).
4. Effluent Tee Filter present? ❑ Yes Q No If yes, was it cleaned? ❑ Yes ❑ No
5 Condition of System:
Okay
6 System Pumped By:
Michael Beausoleil
Name
Bostley Sanitary Service, Inc.
Company
7. Location where contents were disposed.
Ewing waste water Treatment Plant
t‘<6T
Signature of Hauler,
Signature of Receiving Facility
talorm4 doc•03106
Vehicle License Number
Date
Date
/2012
System Pumping Record Page 1 of 1
Commonwealth of Massachusetts
City/Town of
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
1. System Location:
Address
.
t t, \
City/Town
2 System Owner:
lI a( 1 ?_ a uLli )(a( (1 C
Name
Address(if different from location)
MA
State
MA
City/Town State
Telephone Number
tf ( i
Zip Code
Zip Code
R. Pumping Record
1. Date of Pumping - - --— 2. Quantity Pumped:
Date oallons --
3. Type of system: [3 Cesspool(s) [<]. Septic Tank ❑ Tight Tank ❑ Grease Trap
] Other(describe): --- --- - -
4. Effluent Tee Filter present? ❑ Yes'EJ No If yes, was it cleaned? ❑ Yes ❑ No
5 Condition of System:
Okay_
6. System Pumped By:
Michael Beausoleil
Name
Bostley Sanitary Service Inc.-. -
Company
7 Location where contents were disposed:
Erving Waste Water Treatment Plant
5form4.doc 03/06
Vehicle License Number
Signature of Hauler y'
Signature of Receiving Facility
Date
Date
System Pumping Record•Page 1 of 1
Commonweallt of Massachusetts
City/Town of
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 suhi.,tantially the same as that provided here. Before using this form,check with your
local Board of Health to .letermine the form they use The System Pumping Record must be submitted to
the local Board of Healif. or other approving authority within 14 days from the pumping date in
accordance with 310 CN.R 15.351.
A. Facility Information
1. System Location:
/(_-4-4--). S /
Address
X) wfn-r-1/A/ 7L/ MA 0ai2C
Cily/fown State Zip Code
2. System Owner:
Name
Address Of different from location)
MA
City/Town State
Zip Code
Telephone Number
B. Pumping Rectard
1. Date of Pum — 15—/ Z 775-a/0 p m g Date 2. Quantity Pumped:
Gallons
3. Type of system: I] Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe.:
4. Effluent Tee Filter prt sent? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Okay
6. System Pumped By
Michael Beausoleil
Name
Bostley Sanitary Sei vice Inc.
Company
7. L ation where conlents were disposed:
Cg 4a
�+viR Wa�kater 1 reatment Plant
Vehicle License Number
Signature of u 7
•
t
Date
Signature of Receiving Pro.ity Date
l5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of 1nam,p-
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
rortant:When
ig out forms 1. System Location:
:he computer,
only the tab
to move your Ad ess 1
••or-do not a' drII� (1 V1I(�-''tn
the return City— ��`999 k11 t 11N
2. Sys em Owner:
\ Cldr -C C
cc
Name
Address Of different from location)
City/Town
C1G(00
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
1 a2 2 1'S 2. Quantity Pumped: G lons/0
❑ Cess ool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
M Other(describe): 'Q C-h CaTiy\\D-e r
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Ok
t-
6 System Pumped By:
Michael Beausoleil
Name
Bostley Sanitary Service, Inc.
Company
7. Location where contents were disposed:
Montague Wastewater Treatment Plant
gnature of Hauler
Vehicle License Number
i2L3 / J5
Date
Signature of Receiving Facility(or attach facility receipt) Date
,forn4.doc•11/12 System Pumping Record•Page 1 of 1