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25 Pumping Report 2018 (3) Commonwealth of Massachusetts '=a'j= City/Town of Northampton t- I System Pumping Record ..�.f w, Form4 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 8C Deaconess Road Address(if different from location) Concord MA City/Town 01742 State Zip Code 9788313085 Telephone Number B. Pumping Record 1. Date of PumIn 06/04/2018 1500.0000 p 9 Date 2. Quantity Pumped: Gallons 3. Component: ❑Cesspool(s) ©Septic Tank 0 Tight Tank n Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes©No If yes,was it cleaned? ❑Yes n No 5. Observed condition of component pumped: .11nrral „ t-r ley-P-1-.01n Hot tnm_al,'dgp-_A:n rnp ,D1.15 Md1ILl'no Clear__No fi 1tc1. -1-sFresentvr, die Lduk, I - . . .- . -. • . • -. . - _ - . Cover(s) secured. Pulled 18O0g from lift station. Backwashed. Emptied to bottom, and silenced low level alarm. 6. System Pumped By: Andrew Ferrier Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste 4110, Hudson, MA 01749 Company 7. Location where contents were disposed: NECE yard at Field Office: 14 Dollar Ave, Wilbraham, MA 01095 06/04/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1