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25 pumping record 2017 (2) ‘ . Commonwealth of Massachusetts City/Town of Northan.pcon 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 01060 City/Town State Zip Code 2. System Owner: New England Deaconess Assoc. Name 80 Deaconess Road Address(if different from location) Concord MA 01-742 City/Town State Zip Code 97883:3085 Telephone Number B. Pumping Record 06/13/2017 1500.0000 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: Cesspool(s) © Septic Tank ❑ Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? 0 Yes❑X No If yes,was it cleaned? Yes Ei No 5. Observed condition of component pumped: High water level. Oin bottom sludge. Oin tcp solids. Main line Not Applicable . Filter condition not applicable. Cover(s) secured. Repa_rs 6. System Pumped By: Andrew Ferrier Name Vehicle License Number Wind River Environmental, LLC, 377 Main Street, Ste #110, Hudson, MA 31749 Company 7. Location where contents were disposed: NECE yard at Field Office: 14 Dollar Aye, Wilbraham, MA 01095 Customer not on site 06/13/2017 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 a 5 -.y )my\no t &,01 System Pumping Record•Page 1 of 1