811 pumping record Commonwealth of Massachusetts
,`A City/Town of Northampton
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 North King Street
Address
Northamoton MA 3 1 C 6C
City/Town State Zip Code
2. System Owner:
Mass JOT
Name
668 South Avenge
Address(if different from location)
Weston MA C2493
City/Town State Zip Code
6:79737235 xAnn _
Telephone Number
B. Pumping Record
101. Date of Pumping 07/06/2017 2. Quantity Pumped: allons 303
Date Gallons
3. Component: Cesspool(s) Septic Tank ❑ Tight Tank El Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes lL No If yes,was it cleaned? ❑ Yes 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 411C, Fuca on, MA 01749
Company
7. Location where contents were disposed:
NECE yard at Field Office: 14 Dollar Ave, Wilbraham, MA 3139.=
Customer not on site 07/06/2C17
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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