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25 Pump Report Commonwealth of Massachusetts •= m City/Town of Northampton System Pumping Record '11-7,1 Form 4 °ba..S 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 11/23/2018 2. Quantity Pumped: 3000.0000 Date Gallons 3. Component: ❑Cesspool(s) Septic Tank ❑Tight Tank Grease Trap nOther(describe): 4. Effluent Tee Filter present? Yes © No If yes,was it cleaned? n Yes IT No 5. Observed condition of component pumped: mnrrnAl hnitam a,nd,3c 9;n fnu cp,l S Tn,al- bacf,cs rut. main eine Clear. Ao filLue i., pLubuu on the tank, LULLel(e Lot k a., n t de.,iyuLd LU be used with a filter. Cover(s) secured. System is operating ok at this time, some sludge at bottom of tank, cover is secured, . 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: The Metropolitan District Commission: 240 Brainard Rd, PO Box 800, Hartford 11/23/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5fom4doc•11/12 System Pumping Record•Page 1 of 1