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25 Pumping Report (5) Commonwealth of Massachusetts City/Town of Northampton g=am'= o 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 Zip Cods 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 09/09/2018 Quantity Pumped: 1500.0000 Date2. Gallons 3. Component: Cesspool(s) © Septic Tank Tight Tank ❑Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑Yes xi No If yes,was it cleaned? 9 Yes ❑ No 5. Observed condition of component pumped: N...m.• ,,,ter levo] a;nn 1 dT FFyes pct. be used with a filter. Cover(s) secured. Wipes gloves and few diapers in tank, cover is secured, blue wire to pump has been pinched by orange grate cover , might need rump service to come fix not sure if it s causing a problem yet , . 6. System Pumped By: Steven Stewart Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01799 Company 7. Location where contents were disposed: NECE yard at Field Office: 14 Dollar Ave, Wilbraham, MA 01095 09/09/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5fom4.doc•11/12 System Pumping Record•Page 1 of 1