54 System Pumping Records L\
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 15.351.
A. Facility Information
Int:
ling 1. System Location:
son ®-
iputer,
y the Address
to NORTHAMPTON MASS
our
do City/Town State
the 2. System Owner:
ey
BRENDA FLYNN
-•y.-� Name
Address(if different from location)
I V State
CityfTown State
586 1347
Telephone Number
01060
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping NOVEMBR 2, 2. Quantity Pumped: 1500
2012 Gallons
3. Component: ❑ Ces pool(s) ® Septic Tank L Tight Tank ❑ Grease Trap
❑ Other
(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? n 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
SILVER/YELLOW HAULER L66-868
Vehicle License Number
Date
Signature of Receiving Facility(or attach facility receipt) Date
am4 doc•11/12 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 15.351.
A. Facility Information
rant:
filling 1. System Location:
ms On
pulteo r, 54 SYLVESTOR ROAD
ily the Address
✓to NORTHAMPTON /FLORENCE MASS. 01060
your
-ur City/Town State Zip Code
atne
key 2. System Owner:
fl BRENDAN FLYNN
Name
•��'j1
Address(if different from location)
V €laQRENCE
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping NOVMBR 14, 2. Quantity Pumped: — 1500
2014 Gallons
3. Component: El 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:
HIGH WATER LEVELS
6. System Pumped By:
LUIS
Name
CLEAN SEPTICS INC
Company
7. Location where contents were disposed:
BONDI'S ISLAND INDIAN ORCHARD
ORANGE/SILVER MACK
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
orm4.doc•11/12 System Pumping Record•Page 1 of 1