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88 Pump Report 2018 Commonwealth of Massachusetts ,T-,=_a City/Town of Florence :-„a System Pumping Record f Form 4 `i 6� 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: 88 Maple Ridge Road Address Florence MA 01062 City/Town State Zio Code 2. System Owner: Caroline Johnson Name 88 Maple Ridge Road Address(if different from location) Florence MA 01062 City/Town State Zip Code 9134549860 Telephone Number B. Pumping Record 1. Date of Pum in 06/19/2018 2 Quanti Pumped: 1500.0000 p 9 Date tY Gallons 3. Component ❑Cesspool(s) © Septic Tank ❑Tight Tank ❑Grease Trap FL Other(describe): 4. Effluent Tee Filter present? ❑Yes g( No If yes,was it cleaned? ❑Yes n No 5. Observed condition of component pumped: Systenrp=_r ng Pini., No mJ w tnrevel ^+, .^ ate.tnp smlrta Mod=e•ra hnrrnm. - siudg_. BuLII baLf1e8 ace iuLau. main Fine cleat. du filLeL io piesenL uu the Lank, current tank is not designed to be used with a filter. Recommended Boost additive,Installing a riser. Covers) secured. Customer wants risers to grade 24 in round cover one compartment tank. 6. System Pumped By: Scott Brusseau Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01799 Company 7. Location where contents were disposed: WWTF Palmer: 1 Norbell Street, Three Rivers, MA 01080 _ 06/19/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4 doc•11/12 System Pumping Record•Page 1 of 1