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.- •