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27 Pump Record 12-5-17 _gI/ Commonwealth of Massachusetts w City/Town of Florence t) 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: 2/ Spruce Ln _ Address - -- - Florence MA 01062 City/Town State Zip Code 2. System Owner: Mark Goggins Name 21 Spruce 2n Address(if different from location) Florence _ _ MA 01062 _ City/Town State Zip Code 4135753078 Telephone Number _B. Pumping Record 12/05_/201/ 1530.0000 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: n Cesspool(s) © Septic Tank ❑ Tight Tank n Grease Trap n Other(describe): 4. Effluent Tee Filter present? © Yes n No If yes,was it cleaned? k( Yes n No 5. Observed condition of component pumped: Normal water level. Moderate top solids. Moderate bottom sludge. Both baffles are intact. Main line Clear. Filter is present and has been 6. System Pumped By: Chri.stian Jensen Name Vehicle License Number Wind River Env_ronmental, LLC, 527 Main Street, Ste #113, Hudson, MA 01/49 Company — 7. Location where contents were disposed: The Metropolitan District Commission: 240 Braitdrd Rd, PO Box 800, Hartford 12/05/2017 Signature of Hauler Date Signature of Receiving Fadlity(or attach facility receipt) Date t5form4.tloc•11/12 System Pumping Record•Page 1 of 1