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653 System Pumping Records ystem Pumping Report Greg's Wastewater Removal 239 A Greenfield Road South Deerfield, MA 01373 Phone 413-665-3989 Fax 413-665-7358 *** This report will be sent to the BOARD OF HEALTH within 15 DAYS Permit# gRP-a011-422) MA License# Date of Pumping /Af/ / C Property Owner KAREN SHELDON Home Phone Bus Phone L'ell Phone rank Size: (413) 586-3871 1500 GAL 2 COMP. Concrete Good Address Address 2 Address 3 City FLORENCE State MA Zip Code 01062 Total Volume: /S00 Oct Tank Location CUSTOMER HAS Septic /` Holding Tank ' Leach Tank Cesspool Grease Trap )ate of Previous Pumping, If Known: I( "?C) — Naste Received at Licensed Facility: 1�Q[�Q \/ _icensed Facility Phone Number: / U v� '" rown: M G-9 U9 Misc Comments: Driver: Created 9/30/2015 at 9:43:19 AM Page 1 of 1 Commonweal ��// of jvlassachusetts City/Town of °i"''kh System Pumping Record Form 4 Dv) a y-e- 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 Importan When flli g out 1. System Location: forms on the computer,use only the t b key Address to move your cursor-do not use the return key. 2. y tem Owner: 4 9 S/-4 t LtdN ,,3 t,ULLS?ti.infirm R12 City/Town State Zip Code fan ddress(if different from location) City/Town State .. ode elephone umber Pumping Record ty{�7 1. Date of Pumping Ot ° " ' 2. Quantity Pumped: callous lbw 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe)• 4. Effluent Tee Filter present? ❑ Yes yJ No If yes,was it cleaned? es 0 No 5. Condition of System: 6. Systertypymt)ped By: Name 1 Lif Company 7. �LLoc11ation w re contents were disposed: iv Vehicle License Number Signature of Hauler Date Signature of Receiving Facility Date t5form4.dac•C3/06 System Pumping Record•Rage 1 0". 1.- •