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25 Pumping Report 2018 (8) Commonwealth of Massachusetts City/Town of Northampton '- 1 System Pumping Record Form 4 DEP has providedy the thismform for roede local Before of singlthi farm formscheck may be used,but the information t mete be they ue.Ththestauthat yRd here.must befb d this hengcheckdwith your WortthBoard pproving uo horey ine within the form they use.The SystemmPumping Record mu submittedMRto the local Board of Health or other approving au[hodH 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 Zo Code 2. System Owner: New England Deaconess Assoc. Name 80 Deaconess Road Address Of different from location) Concord MA 01792 City/Town State Zip Code 9788313085 Telephone Number B. Pumping Record 1. Date of Pumping 07/27/2018 2. Quantity Pumped: 1500.0000 Dale Gallons 3. Component: n Cesspool(s) © Septic Tank Tight Tank 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: Trw 6at6r level Ilin hnttn,n sludge u:., t„p enlidc_ g,.th b.ff1oa amp.. intact.-.-1.4.3-141— line ...a n line :1eaL. du filLer _s ptesenL an Lhe Lank, LULLCIL LdIA m nog de, iyusd Lu be used with a filter. Cover:s) secured. No rags or diapers thrown in into pump area , some sludge at bottom of tank. 6. System Pumped By: Steven Stewart _ Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: NECE yard at Field Office: 14 Dollar Ave, Wilbraham, MA 01095 07/27/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5fonn4.doc•11/12 System Pumping Record•Page 1 of 1