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136 Pump Report 2018 (4) Commonwealth of Massachusetts G; (>76 City/Town of Northampton System Pumping Record Form 4 ?2DEP 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. DCR 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 04/09/2018 2. Quantity Pumped: 2000.0000 DateGallons 3. Component: ❑ Cesspool(s) ©Septic Tank ❑Tight Tank ❑Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes © No If yes,was it cleaned? n Yes n No 5. Observed condition of component pumped: vnrm,1 -,.for lo„or a:, boffnr, ,r„dqo Rin rnp #olids. Inlet. b=rrtoe =ro :nf=cf Mdiu lice Cledr. #u fillet is plea- • - - • - - - - •• -• with a filter. Cover(s) secured. All goo5 ,could use boost or ccls and filter. 6. System Pumped By: Steven Stewart 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 04/09/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1