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25 Pumping Report (3)
L\ Commonwealth of Massachusetts k,,,, City/Town of Northampton ■=N 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: 25 Coles Meadow Road Address Northampton MA 01060 City/Town State Zio Code 2. System Owner: New England Deaconess Assoc. Name 80 Deaconess Road Address(if different from location) Concord MA 01742 City/Town State Zip Code 9788313085 Telephone Number B. Pumping Record 1. Date of Pumping 08/23/2018 2. Quantic Pumped: 2000.0000 p g Datey p Gallons 3. Component: ❑ Cesspool(s) ©Septic Tank I Tight Tank ❑Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? n Yes© No If yes,was it cleaned? E Yes n No 5. Observed condition of component pumped: Sint npplica ie tutor 1 -vel. Sin hnttnm Ludgo lin {imp snl irle Min 1;., - filter. Cover(s) secured. System Evaluation recommended . Emptied PC TO bottom and backwashed. Pulled 2000g. Customer states that trash keeps clogging pumps. Recommend system evaluation based on customer complaint. 6. System Pumped By: Andrew Ferrier . Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: WWTF Palmer: 1 Martell Street, Three Rivers, MA 01080 08/23/2018 Signature of Hauler Date Signature of Receiving Fadlity(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1