31 System Pumping Record 2016 Commonwealth of Massachusetts
}p City/Town of Florence
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:
31 Fairway Drive
Address
Florence MA 0' 062
City/Town State Zip Code
2. System Owner:
Brent Delano
Name
31 Fairway Drive
Address Of different from location)
Florence MA
01062
City/Town State
4132309054
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
11/02/2016 2. Quantity Pumped:
Date
Cesspool(s) Septic Tank ❑ Tight Tank
1500.0000
Gallons
Grease Trap
nOther(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes n No
5. Observed condition of component pumped:
Normal water level. Light top solids. Moderate bottom sludge. Both baffles
are intact. Matn line Clear. Filter missing. Recommended Boost additive,
6. System Pumped By:
Charles Hartwell
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
11/02/2016
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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