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25 Pumping Report Commonwealth of Massachusetts Q''_ 1 _ City/Town of Northampton ,Mleg System Pumping Record fit,a---1 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 Zia Code 2. System Owner: New England Deaconess Assoc. Name 80 Deaconess Road Address(if different from location) Concord MA 01742 City/Town State Zip Code 9788313085 Telephone Number B. Pumping Record 1. Date of Pumping 09/21/2018 _ 2. quantity Pumped: 1500.0000 DateGallons 3. Component: Cesspool(s) Septic Tank D Tight Tank n Grease Trap Other(describe): 4. Effluent Tee Filter present? Yes © No If yes,was it cleaned? ❑Yes No 5. Observed condition of component pumped: mnrmar waror tova1 5i n_tuottom aJ„dga 2i., fmr, enliela Main llnc r1ean a ,1... is pii5uu w, LLe Lank, Luciuu. Lduk i., LwL de.,iyned La be used wiLl, d filler. Cover(s) secured. Emptied lift station to bottom. Backwashed. 6. System Pumped By: Andrew Ferrier Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste 4110, Hudson, MA 01749 Company 7. Location where contents were disposed: NECE yard at Field Office: 14 Dollar Ave, Wilbraham, MA 01095 09/21/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5fom4doc•11/12 System Pumping Record•Page 1 of 1