421 System Pumping Records Owner
rte Management
Patriot Place
cboro, MA, 02035
)8)-962-3671 x
ngalninaae
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
Form 4--System Pumping Record%
System Location
VAMC Northampton Campus
Leeds, MA, 01053
(315)-767-4745 x
Josee Goldin
Emergen Routine
No Yes
Pumping: 7-(<D
Cc,--tch tics
Septic Tonk: No Yes
Quantity Pumped: Gallons
Pumped By: Wind River Environmental,LLC
rs Transferred ta:
Permit#:
is Disposed at:
'7^15 Pumper Signature:
ion of System/Other Comments
Dc-
Dep Approved Form-12/07/95
nine
Meng and
on the
tier,use
*tee key
es your
rein nut
he when
o(G//P POIJsi
Commonwealth of-� �achfla
City/Town of tit r'�' ,-"
System Pureeing-Record -
Form 4 but the
DEP has provided U font for use by local Boards of Heath.art Other Before using Miami, ut the chador/lib your
information must be substantally the same as that provid, stem Before Record must be submtted ur
t local Board of of Health doreothee approving they use.The 14 days from the pumping date in -
acc ence with 310 MCMR 15.36 .
A. Facility Information
1. system Location:
Address
q(yAbwn
2 .,h'elwn,owner:
ne u4v MP-DWI sr,
Zips
fu se(e different from WART)
_----
ahyrtamn
B. Pumping Record
A. Date of Pumping osn,
3, Type of system: - PE Cesapoogs) ❑
❑. Other.(describe): -
4. Effluent Tee Filter present? ❑ Yes
5. Condition.of System:
(N-0o0_
B. SySiBm roped By
stiff 5--licrlior
Meter "
__---,,;,z. Quantity moped:
Septic Tank ❑ Tight Tank
If yes,was it leaned/
50Do
Gallons
LFl cease Trap
0 Y
ralro
0004.do •05106
soma animist. •
Signetus or Rambling Facility
System Puepbe Revere•page,at I