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50 PUmp Report 2018
Commonwealth of Massachusetts pL_, City/Town of Florence System Pumping Record i +//. —/, Form 4 SfY 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: 50 West Farms Road Address Florence MA 01062 City/Town State Zio Code 2. System Owner: Mike Skowronek Name 50 West Farms Road Address(if different from location) Florence MA 01062 City/Town State Zip Code 4139238394 — Telephone Number B. Pumping Record 05/26/20181000.0000 1. Date of Pumping Dam 2. Quantity Pumped: Gallons 3. Component: D Cesspool(s) © Septic Tank ❑Tight Tank 0 Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? 0 Yes © No If yes, was it cleaned? fl Yes ❑No 5. Observed condition of component pumped: ao mai_i.Later leve-1_ Nederato_Sfp o1:ri ._ociefdte-Gott^m 41 'Tr M4,n line—Clear— - • filter. Recommended CCLS additive.,Cover(s) secured. Cele recommend, sludge at bottom 4 inches. 6. System Pumped By: Steven Stewart Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: The Metropolitan District Commission: 240 Brainard Rd, PO Box 800, Hartford 05/26/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1