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25 Pumping Report 2018 (4) Commonwealth of Massachusetts *= City/Town of -z\ � y Northampton System Pumping Record mti=,y 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 1. Date of Pumping 06/26/2018 Quantity Pumped: 3000.0000 Dale2. Gallons 3. Component: ❑Cesspool(s) ©Septic Tank Fl Tight Tank 0 Grease Trap 7 Other(describe): 4. Effluent Tee Filter present? ❑Yes © No If yes,was it cleaned? n Yes ❑ No 5. Observed condition of component pumped: vnrmal wa ar Laval min hnftnm sludge Sin.top-sad:H5 Main lino Unt npp?ypajaye___ _ NO fi.Ler ib pre.,cnL al she Lank, miiu,L ..auk la eon designed w be used wile d filter. Cover(s) secured. Removed 3000 gallons from pump chamber. 6. System Pumped By: Donald Callender 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: 290 Brainard Rd, PO Box 800, Hartford .d /. 06/26/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1