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25 Pumping Report (2) Commonwealth of Massachusetts 1L_c Vo. City/Town of Northampton System Pumping Record POrtyl4 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 Zip 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 09/28/2018 2. Quantity Pumped: Dale GaGallons0000 3. Component: ❑ Cesspool(s) © Septic Tank ❑Tight Tank ❑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: Normal vP 5in bot- nm o4ge`fin tcp_spj_Lop Main J;n= r1oa me f'jcp,- is prc,bLie Cu Abe Lank, cuuene Lank is uuL desiyu..d Lu be ue..d with e Iliter. Cover(s) secured. 6. System Pumped By: Andrew Ferrier Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01799 Company 7. Location where contents were disposed: 09/28/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date 15form4.doc•11/12 System Pumping Record•Page 1 of 1