811 pumping record MassDOT 2017 Commonwealth of Massachusetts
5=i-_--t City/Town of Nortriampton
=`: 3� i 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:
811 `tort: King_ Street
Address
Northampton MA 01060
City/Town State Zip Code
2. System Owner:
Mass DOT
Name
66E, South Avenue
Address(if different from location)
Weston heir 02493
City/Town State Zip Code
.6179737235 xAnn
Telephone Number
B. Pumping Record
07/05/2017 'CC C .
1. Date of Pumping
2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) lL Septic Tank El Tight Tank 0 Grease Trap
El Other(describe):
4. Effluent Tee Filter present? n Yes g No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
High water level. 4in_ bottom sludge. 4in top solids. Inlet baffles are
intact. Main line Clear. Filter condition not applicable. Cover(s)
6. System Pumped By:
Lee Gourinski
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste =110, Hudson, MA 01749
Company
7. Location where contents were disposed:
NECE yard at Field Office: :4 Dollar Ave, Wilbraham, MA 01095
07/35/2C17
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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