25 pumping record 2017 Commonwealth of Massachusetts
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17:1' = 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:
25 Coles Meadow Road
Address
Northampton MA O1C6C
City/Town State Zip Code
2. System Owner:
New England Deaconess Asset.
Name
80 Deaconess Road
Address(if different from location)
Concord MA 01742
City/Town State Zip Code
9%88313085
Telephone Number
B. Pumping Record
1. Date of Pumping 06/13/2017 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: El Cesspool(s) ❑X Septic Tank ❑ Tight Tank Grease Trap
n Other(describe):
4. Effluent Tee Filter present? n Yes kC No If yes, was it cleaned? ❑ Yes 0 No
5. Observed condition of component pumped:
High water level. Oin bottom sludge. Oin too solids. Main line Not
Applicable . Filter condition not applicable. Covers) secured. Repairs
6. System Pumped By:
Andrew Ferrier
Name Vehicle License Number
Wind River Environmental, ILO, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
NECE yard a= Field Office: 14 Dollar Ave, Wilbraham, MA 01095
Customer not on site 06/13/2017
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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