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668 pumping record 2017 Commonwealth of Massachusetts � City/Town of Northarr.po.on , 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 310CMR 15.351. A. Facility Information 1. System Location: __ North :<ing Street Address Northampton MA 01060 City/Town State Zip Code 2. System Owner: Mass DOT Name 668 South Avenue Address(if different from location) Weston MA 02993 City/Town State Zip Code 617973 7235 x?-- Telephone Number B. Pumping Record 1. Date of Pumping 07/06/2017 _ 2. Quantity Pumped: 1000.0000 DateGallons 3. Component: fl Cesspool(s) © Septic Tank 0 Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes© No If yes, was it cleaned? El Yes 0 No 5. Observed condition of component pumped: High water level. 2in bottom sludge. lin top solids. Main line Not Applicable . Filter condition not applicable. Serviced pump chamber for 6. System Pumped By: Andrew Ferrier Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: INCE yard a= Field Office: 14 Dollar Ave, Wilbraham, MA 01095 Customer not on site 07/06/2017 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date 15form4.doc•11112 "p D% 'Vt``l q4_ , , ,.rC1 �O ,�{ System Pumping Record•Page 1 of 1