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421 Pump Report 2018 Commonwealth of Massachusetts ffcgfr I City/Town of reeds System Pumping Record 7 Form 4 x.y7 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: 421 North Main Address Leeds _ - MA 01053 City/Town State _ Z2ii Code 2. System Owner: VA Medical Northhamptoc Campus Name 421 North Main Address(if different from location) Leeds MA 01053 Dry/Town State Zip Code 2076238911 x2226 Telephone Number B. Pumping Record 1. Date of Pumping 03/19/2018 __ 2 Quantity Pumped: 1000.0000 Date Gallons 3. Component: ❑Cesspool(s) © Septic Tank ❑Tight Tank ❑Grease Trap 0 Other(describe): 4. Effluent Tee Filter present? n Yes © No If yes, was it cleaned? ❑Yes n No 5. Observed condition of component pumped: nrnrm,1 „-nor level. 12in bot-tom—alaiar bot—tom—atap soiid M-an tin,. near. Na-€_i_i_sr is present un We LeuA. LurLIll tank IS uUL desiyued Lu be used with e filve1. Cover(s secured. 6. System Pumped By: Michael Bloom Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: The Metropolitan District Commission: 240 Brainard Rd, PO Box 800, Hartford • 03/19/2018 Signature of Hauler Date Signature of Receiving Fadlity(or attach facility receipt) Date t5form4 doc•11/12 System Pumping Record•Page 1 of 1