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25 pumping record Commonwealth of Massachusetts City/Town of 'Northampton fry ate 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: 136 Damon Road Address Northampton MA 01060 City/Town State Zip Code 2. System Owner: Commonwealth Dept. DCR Wes:ern Region Name PO Box 1433 Address(if different from location) Pittsfield _ MA 01202 City/Town State Zip Code 4_33395504 Telephone Number B. Pumping Record 06/06/2017 2CCC.CC00 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: Cesspool(s) lL Septic Tank Tight Tank [1 Grease Trap El Other(describe): 4. Effluent Tee Filter present? Yes© No If yes, was it cleaned? n Yes J No 5. Observed condition of component pumped: Normal water level. Oin bottom s=•._dce. Oin _op solids. Main line Clear. Filter condition not applicable. Cover(s) secured. 6. System Pumped By: Andrew Ferrier Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #113, Hudson, MA 011749 Company 7. Location where contents were disposed: NECE yard at Field Office: 14 Dollar Ave, Wilbraham, MA 01095 ;-4L 06/06/2017 Signature of tulb? Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 \•3 1/12 ` �j t r 5 \ 0�� System Pumping Record•Page 1 of 1 � 1.b