100 Pumping Report System Pumping Reporta 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#'WC) )Lfl MA License# Date of Pumping `6 I d I
(AC'G\L
Address 100 BLACK BIRCH TRAIL
Property Owner ROCKY HILL CONDO ASSOC Address 2
Home Phone 413-923-4675 Address 3
Bus Phone City FLORENCE
Cell Phone State MA Zip Code 01062
Total Volume: -C-')
Tank Size: 5000 GAL
INJECTOR PUMP--
Good
Tank Location
Septic PrHolding Tank Leach Tank Cesspool ri Grease Trap
Date of Previous Pumping, If Known: -CZ JV I 1�*V'\/ Ic\
Waste Received at Licensed Facility: 'd 11U)1 P 1 \9±PD I
Licensed Facility Phone Number: Lc1
Town: H CVS h lc\ \o-+Thn
Misc Comments:
Driver: A
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