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421 Pump Report 12-28-17 Commonwealth of Massachusetts a1 =y City/Town of Leeds (b ce-Vv..M•p\c,. 1 gii System Pumping Record 3(,\' � ,(s 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: 421 North Main Address Leeds MA 01053 City/Town State Zip Code 2. System Owner: VA Kedical NorLFharpton Campus Name -- 421 North Main Address(if different from location) - -- Leeds _ _ MA _ 01053 City/Town State Zip Code 2076238411 x2226 Telephone Number B. Pumping Record 1. Date of Pumping 12;28/20172 QuantityPumped: loon.0000 Date p Gallons 3. Component: Cesspool(s) ©Septic Tank n Tight Tank n Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes © No If yes, was it cleaned? n Yes ❑ No 5. Observed condition of component pumped: Nct_ applicable._�•• 4�leve1—2�n hottcm sl n,in=_-0in Inn ".ids main line C'aa _ No rifler .s preber.r VII tt1- - - • •- • - 1 LU bL w_rh filter. cover(s) secured. Pumped pump c:hamber, raked grate , 1000 gals. 6. System Pumped By: Christian Jensen Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01799 Company 7. Location where contents were disposed: The Metropolitan District Commissicn: 240 Brainard Rd, PO Box 800, Hartford 12/28/2017 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4 doc•11/12 System Pumping Record•Page 1 of 1