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25 Pumping Report 2018 (6) Commonwealth of Massachusetts City/Town of Northampton iti System Pumping Record �- � For4 y DEP hasm 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 Beare 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 Zip Code 2. System Owner: New England Deaconess Assoc. Name 80 Deaconess Road Address(if different from location) Concord MA 01792 City/Town State Zip Code 9788313085 Telephone Number B. Pumping Record 05/08/20182500.0000 1. Date of Pumping Date 2. Quantity Pumped: canons 3. Component: Cesspool(s) © Septic Tank El Tight Tank 0 Grease Trap 9 Other(describe): 4. Effluent Tee Filter present? ❑Yes© No If yes,was it cleaned? 9 Yes 9 No 5. Observed condition of component pumped: f ae verui atar level_ 1-0in_batrvm s-Ludgerla'^ rrp olids_ ta - a.o iiue_Clear. n i. presenL Oil Lie Lank, Lulluct. Ler,k ie flue deslyued LU to used NILE e filler. Coverts) secured. Pulled 2500g from PC. 6. System Pumped By: Andrew Ferrier Vehicle License Number Name Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01799 Company 7. Location where contents were disposed: Robert Parent: 1208 Woods hill Rd, Sheldon, VT 05843 05/08/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11)12 System Pumping Record•Page 1 of 1