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136 Pump Report 9-29-17 Commonwealth of Massachusetts R _ City/Town of Northampton Il 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 Da:non Road Address - -' - Northampton MA _ 01010 City/Town State Zip Code 2. System Owner: Commonwealth Dept. DCR Western Region Name - - PO Box 1933 Address(if different from location) - - Pittsfield MA _ 0i202 Cityliown State Zip Code - 4133395504 Telephone Number -B. Pumping Record 09/29/2017 2000.0 1. Date of Pum In :]GC p g Date 2. Quantity Pumped: - • Gallons 3. Component: 0 Cesspool(s) © Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? Q Yes© No If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: High water level. Din bottom sludge. Oin top solids. Poch baffles are intact. Main line Clear. No filter is present on the tank. Cover(s) 6. System Pumped By: Francis Gibney Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste 4110, Hudson, MA 01749 Company 7. Location where contents were disposed: Water Solutions Group: 35 Mos zone Blvd , Taunton, MA 02780 customer not an site 09/29/2017 Signature of Hauler —' - - - - Date Signature of Receiving Facility(or attach fatuity receipt) Date 15fom 4.doc•17/14 System Pumping Record•Page 1 of 1