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136 Pump Report 2018 Commonwealth of Massachusetts _'- .9 City/Town of Northampton Sit-7- System Pumping Record Form 4 DEP has provided this form that use by local here. efor of Health.Other forms ec may o used,but theinformation t metebe rm they use. h same as providedcormusBefore ted this form. ok with your localnBoard of Healthingto determine the form they The SystemmPumping Record submittedto 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 Western Region Name PG Box 1433 Address Of different from location) Pittsfield MA D1202 City/Town State Zip Code 4/33395504 Telephone Number B. Pumping Record 1. Date of Pumping 06/22/2018 2. Quantity Pumped: 400.0000 Date Gallons 3. Component: Cesspool(s) © Septic Tank n Tight Tank n Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes© No If yes,was it cleaned? ❑Yes n No 5. Observed condition of component pumped: NnrnM1 ,..]rar avert nlr nntt-n-a_sludge_ ^in Lnm nelian mein line Cl==. Mn f 1roc is-presem_ On Lhe wino, ILLULL rank ik uur de.,igaeno—te used wiLh d filiei. Cover(s) secured. Repairs needed: Repair call to check float switch and overtul light operations. Outside light did not come on when level is overful today. Repair call to check float switch and overful light operations. Outside light did not come on when level is overful today 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: NECE yard at Field Office: 14 Dollar Ave, Wilbraham, MA 01095 06/22/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1