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25 Pumping Report (4) • Commonwealth of Massachusetts 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: 25 Coles Meadow Road Address Northampton MA 01060 City/Town State 3io 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 09/12/20183500.0000 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: fl Cesspool(s) ©Septic Tank 0 Tight Tank ❑Grease Trap EOther(describe): 4. Effluent Tee Filter present? ❑Yes©No If yes,was it cleaned? 0 Yes ❑ No 5. Observed condition of component pumped ,o me F.r.o —is— y:0h w _ oreue 9 � botfm 1 I dge-. 1 i n top ff yLabLub 6n Ole Lank, wiseIL tank is IOL debiyned to be u.,..d wtlr, a ril Ler. Serviced lift station for Blake equipment Pulled 3500g. 6. System Pumped By: Andrew Ferrier Vehicle License Number Name Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: NECE yard at Field Office: 14 Dollar Ave, Wilbraham, MA 01095 09/12/2018 Signature of Hauler Date Signature of Receiving Facility(or attach fadlity receipt) Date t5fomr4 d0c•11/12 System Pumping Record•Page 1 of 1