776 Pump Report 2020Commonwealth of Massachusetts
City/Town of Northampton
System Pumping Record
1% 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 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
Important: When
filling out forms 1.
on the computer,
use only the tab
key to move your
_
cursor _do not
use the return
key.
� N
System Location
Address
City/Town
System Owner:
Name
Address (if different from location)
B. Pumping Record
1. Date of Pumping
776 North King Street
Northampton. MA — _
11/23/2020
State Zip Code
State
Telephone Number
Zip Code
1,500
2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑
Other (describe):
4. Effluent Tee Filter present? ❑X Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By
Mike Beausoleil
Name
Bostley Sanitary Service, Inc.
Company
7. Location where contents were disposed:
Greenfield Wastewater Treatment Plant
Signature of
Signature of Receiving Facility (or attach facility receipt)
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
11/23/2020
Date
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