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811 Pump Report 2018 (2) Commonwealth of Massachusetts City/Town of Northampton e' System Pumping Record C 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 bnn 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: 811 North King Street Address Northampton MA 01060 City/Town State Zai Code 2. System Owner: Mass DOT Name 668 South Avenue Address(if different from location) Weston MA 02993 City/Town State Zip Code 6179732235 xnis Telephone Number B. Pumping Record 1. Date of Pumping 07/26/2018 Quantity Pumped: 1000.0000 Date2. Gallons 3. Component: ❑Cesspool(s) ©Septic Tank n Tight Tank 7 Grease Trap 0 Other(describe): 4. Effluent Tee Filter present? rl Yes© No If yes, was it cleaned? 7 Yes ❑ No 5. Observed condition of component pumped: P„m s -ant worlOng; rcm^v,H lnnn gallon - 6. System Pumped By: Steven Stewart _ Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste 9110, Hudson, MA 01749 Company 7. Location where contents were disposed: WWTF Palmer: 1 Norbell Street, Three Rivers, MA 01080 07/26/2018 'Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1