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29 pumping report Commonwealth of Massachusetts 17}I CSyst of Florence Systemm 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 o 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: 29 Hawthorne Terrace - Address Florence _ MA 01062 City/Town State Zip Code 2. System Owner: Renee Mayer Name 29 Hawthorne Terrace Address(if different from location) Florence MA 01062 City/Town State Zip Code 4137278/29 - _ Telephone Number B. Pumping Record 10/13/20182000.0000 1. Date of Pumping Dam 2. Quantity Pumped: Gallons 3. Component: ❑Cesspool(s) © Septic Tank I Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes © No If yes,was it cleaned? ❑Yes ❑ No 5. Observed condition of component pumped: Bet.,,m �p�rem not npo ar'sr pi me J:gh +coater—level —Madesats e—toe se lid _keavcy .,ludye. Hain rine Cleric. Nu Y lit,: is pceriuu mt dm tank, LuLienL Lank i., not designed to be used with a filter. Recommended Boost additive, CCLS additive. Cover(s) secured. System was very high when I got here, pumped out to bottom of tank, some sludge at bottom of tank, covers are secured, also have a pump chamber I pumped out, pump not working recommend service pump . . Recommend cels and boost 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: NECE yard at Field Office: 14 Dollar Ave, Wilbraham, MA 01095 10/13/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 TOWN OF PALMER Oper. /CC WATER POLLUTION CONTROL FACILITIES pH 7 / SEPTAGE DISPOSAL TICKET # Q 12.5- I , 2.5-I , the Carrier , wish to dischargee,7' _gallons of night soil into the Town of Palmer ' s Wastewater Treatmhhnt Plant . Property Owner : getter - ¢ 1,7/ o?3 Tel.# Z//3- 7,j7—,/a9 Septic Tank Location : /'o"AJ 1f,1jrn? /e rturc, ,Fredi P 4— The undersigned acknowledges the rules and regulations projulgated by the Board of Selectmen and agrees to comply with all its provisions , the instructions and directions of the Chief Operator , and the provisions of the Commonwealth of Massachusetts Sanitary Code as it relates to the handling of night soil . Carrier : ldpel ni Avec tnuiibit4l J Date of Discharge : / 0 -/ Q -A, Time of Discharge : .2 /,r Fee :