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25 Pumping Report (8) Commonwealth of Massachusetts f—=- �i City/Town of Northampton Air+'- t 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 Code 2. System Owner: New England Deaconess Assoc. Name 80 Deaconess Road Address(if different from location) Concord MA 01792 City/Town State Zip Code 9788313085 — Telephone Number B. Pumping Record 11/09/20181500.0000 1. Date of Pumping Date 2. Quantity Pumped: Canons 3. Component: Cesspool(s) © Septic Tank D Tight Tank D Grease Trap Other(describe): 4. Effluent Tee Filter present? Yes© No If yes,was it cleaned? ❑Yes ❑ No 5. Observed condition of component pumped: , e w F., . Ao mar ttn ,. r-lever si . rnrfm _ad9e`_G'a Tap aliH Ls PcLSLnL mr die Lduk, Lei¢JIL Lank is 'UL deslyued Lu be used wiLu a-filter. Covers) secured. 6. System Pumped By: BrianNicoll Vehicle License Number Name Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01799 Company 7. Location where contents were disposed: The Metropolitan District Commission: 240 Brainard Rd, PD Box 800, Hartford 11/09/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date System Pumping Record•Page 1 of 1 t5bm4.tloc•11/12