53 Pump Report 2-2023Commonwealth of Massachusetts
City/Town of
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.
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1
A.Facility Information
1.System Location:
Address
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:Gallons
3. Component: Cesspool(s) Septic Tank 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:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
53 MAIN STREET
MA 01062
Cumberland Farms Corp
2643 Hartford Avenue
02919Johnston
0000000000
RI
03/14/2023 1500.0000
Normal water level. 5in bottom sludge. 1in top solids. Main line Clear. No filter
is present on the tank; current tank is not designed to be used with a filter.
Cover(s) secured. No 3rd party paperwork filled. System operating ok at this time,
some sludge on bottom of tank, covers are secured.
Steven Stewart Sr.
Granville Anaerobic Digester: 355 Granby Road, Granville, MA 01034
03/14/2023
Florence
Florence