53 pumping report Commonwealth of Massachusetts
--rt City/Town of Florence
■- ; System Pumping Record
a` Form 4
b„ 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:
53 MAIN STREET
Address
Florence MA 01062
City/Town State Zip Code
2. System Owner:
Cumberland Farms Corp
Name
2693 Hartford Avenue
Address(if different from location)
Johnston RI 02919
City/Town State Zip Code
9019390397
Telephone Number
B. Pumping Record
1. Date of Pumping 11/27/2018 Quantity Pumped: 1500.0000
Date2. Gallons
3. Component: Cesspool(s) Septic Tank ❑Tight Tank 'NtGrease Trap
❑ Other(describe):
4. Effluent Tee Filter present? n Yes gn No If yes,was it cleaned? n Yes n No
5. Observed condition of component pumped:
Mn.mn1 .,nfn,- 1cvnl e:n b.wfom e1„d0n lin Innin emide Bnth huffing aro Infant
be used with a filter. Cover(s) secured. System is operating ok at this time, some
sludge at bottom of tank, covers are secured. Removed 1500 gallons.
6. System Pumped By:
Steven Stewart
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste 4110, Hudson, MA 0.1749
Company
7. Location where contents were disposed:
Vanguard Renewables- Deerfield: 188 Mill Village Road, South Deerfield , MA
11/27/2018
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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