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79 pump report 2017 Commonwealth of Massachusetts 'LY= ; City/Town of Florence System Pumping Record • v/ 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: 79 Old Wilson Road Address Florence MA 01062 City/Town State Zip Code 2. System Owner: Beth Fitzgerald Name 79 Old Wilson Road Address(if different from location) Florence h1A 01062 City/Town State Zip Code 4136952719 Telephone Number B. Pumping Record 1. Date of Pumping 01/31/2017 -000.0000 2. Quantity Pumped: Date Gallons 3. Component: Cesspool(s) © Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? n Yes kC No If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Normal water level. Heavy top solids. Moderate bottom sludge. Both baffles are intact. Main line Clear. Filter missing. Recommended Boost additive, 6. System Pumped By: Joshua Gray Name Vehicle License Number wind. River Environmental, LLC, 577 Main Street, Ste #113, Hudson, MA 01749 Company 7. Location where contents were disposed: NECE yard at Field Office: 14 Dollar Ave, Wilbraham, :•1A 01095 01/31/2017 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1