540 Septic Pumping Records System Pumping Report
Greg's Wastewater Removal
239 A Greenfield Road
South Deerfield,MA 01373
Phone 413-665-3989 Fax 413-665-7358
****** This report will be sent to the BOARD OF HEALTH within 15 DAYS ******
Permit# 4-�rJl9-0d31 MA License# Date of Pumping ,// i Jd-
Contact
C.N.
Home Phone
Bus Phone
Cell Phone
LINDA MCELANEY
[1]413-584-8033
Address 540 COLES MEADOW ROAD
Address 2
Address 3
City NORTHAMPTON
State MA Zip Code 01060
Total Volume: %S 0
Tank Size:
1500 GAL
Concrete
Good
Tank Location MAP ON FILE, RISER 6" DEEP
0 Septic ❑ Holding Tank ❑ Leach Tank ❑ Cesspool ❑ Grease Trap
Date of Previous Pumping, If Known:
Waste Received at Licensed Facility:
Licensed Facility Phone Number:
Town:
/x '37-64'
V-ti)4J0 CO uJ 7
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Misc Comments:
Driver:
2 f,
Created 11/10/2009 at 4:28 PM
Important:When
filling out forms
on the computer,
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UST
Commonwealth of Massachusetts
City/Town of Northampton
System Pumping Record
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
1. System Location:
540 Coles Meadow Road
Address
Northamapton
City/Town
2. System Owner:
Linda A McElaney
Name
Address(if different from location)
City/Town
MA
State
01060
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
5/15/2015
Date
2. Quantity Pumped:
1,000
Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes C No
5. Observed condition of component pumped:
OK
6. System Pumped By
Michael Beausoleil
Name
Bostley Sanitary Service, Inc.
Company
If yes, was it cleaned? ❑ Yes ® No
Vehicle License Number
7. Location where contents were disposed:
Montague Wastewater Treatment Plant
May 15, 2015
ture of Hau - Date
Signature of Rece
acuity(or attach facility receipt)
Date
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