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136 Pump Report 2018 (2) Commonwealth of Massachusetts City/Town tyown oNorthampton MITSH System Pumping Record Form 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 — - _-- Northampton MA 01060 City/Town State Zip Code 2. System Owner: Commonwealth Dept. OCR Western Region Name PO Box 1433 Address(if different from location) Pittsfield MA 01202 City/Town State Zip Code 9133395504 Telephone Number B. Pumping Record 1. Date of Pumping 07/12/20:8 2. Quantity Pumped: 2000.0000 DateGallons 3. Component: n Cesspool(s) © Septic Tank n Tight Tank n Grease Trap n Other(describe): 4. Effluent Tee Filter present? n Yes R[ No If yes,was it cleaned? Yes No 5. Observed condition of component pumped: water—covet qlo bnttnm etends die eep solids_.Inlet harm es am .ntaef mein line Clear. NO filter IS yre.,uu w, Lim LduR, LULlenL Ldllk is nue deigned se be used with a filter. Cover lsl secured. Some sludge on bottom of tank / inches. 6. System Pumped By: Steven Stewart Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01799 Company 7. Location where contents were disposed: WWTE Palmer: 1 Norbell Street, Three Rivers, MA 01080 07/12/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1