Loading...
136 Pumping Report Commonwealth of Massachusetts ni_**_= City/Town of Northampton —' ' 'a 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 01060 Northampton MA City/Town State Zio Code 2. System Owner: Commonwealth Dept. ECR Western Region Name PO Box 1433 Address(if different from location) MA 01202 Pittsfield State Zip Code CitylTown 9133395504 Telephone Number B. Pumping Record 10/04/20162500.0000 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: 0 Cesspool(s) ©Septic Tank El 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: Ofigh_a4at e beve cftao`t m s1„r19 n;n.top =nl'Ac mai n lisle Clear No fi te-r—is— ihe idek, ouliil.i Ldnk (-d„ t,e UULr1«Cd w'-L„ d n.LCL. ewu (s) S CULCd. pieieni Of Emptied tight tank at high level. Pulled 25009. 6. System Pumped By: Andrew Ferrier Vehicle License Number Name Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: NECE yard at Field Office: 14 Dollar Ave, Wilbraham, MA 01095 10/09/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5forn4 doc•11)12 System Pumping Record•Page 1 of 1