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25 Pumping Report (7) Commonwealth of Massachusetts 1, rr--p, City/Town of Northampton ■1 System Pumping Record C_'`�-1 Form 4 ••"' ++a 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 7'o 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 10/26/2018 1500.0000 1. Date of Pumping Date 2. Quantity Pumped: callous 3. Component: Cesspool(s) © Septic Tank El Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes© No If yes,was it cleaned? El Yes No 5. Observed condition of component pumped: g0rm,1 wester level_ in hpttnm clnr10o 91n tnp enlih= Bnth.h,fflec -re ,nr,rt Main sine Bleu. do filler en paesuIL un the Lank, turreet Leek is not designed Le be used with a filter. Covers) secured. 6. System Pumped By: Brian Nicoll Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste 14110, Hudson, MA 01749 Company 7. Location where contents were disposed: WWTF Palmer: 1 Norbell Street, Three Rivers, MA 01080 10/26/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5forrn4.doc•11/12 System Pumping Record•Page 1 of 1 • TOWN OF PALMER Oper. WATER POLLUTION CONTROL FACILITIES pH 7/ SEPTAGE DISPOSAL TICKET # 90 .7? I , the Carrier , wish to discharge /4-27—/ gallons of night soil into the Town of Palmer ' s Wastewater Treatment Plant . q 9 Property Owner : MOG{K ' 2?& r /2Er'T7'177/40 Tel.# Septic Tank Location : 2r COLES re&ttoeW gip A/o ierr�/h,zw'fit , The undersigned acknowledges the rules and regulations projulgated by the Board of Selectmen and agrees to comply with all its provisions , the instructions and directions of the Chief Operator , and the provisions of the Commonwealth of Massachusetts Sanitary Code as it relates to the handling of night soil . ,, ,,// Carrier : vv ge— / Date of Discharge : �t -210 Time of Discharge : / Sc Fee : j}y9r