Loading...
421 Pump Report 2018 (2) Commonwealth of Massachusetts — /� City/Town of =�I'1 y Leeds r ` '— System Pumping Record •Wi"' , 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: 421 North Main Address Leeds MA 01053 City/Town State Zip Code 2. System Owner: VA Medical Northhamoton Campus Name 421 North Main Address(if different from location) Leeds MA 01053 City/Town State Zip Code 2076238411 x2226 Telephone Number B. Pumping Record 1. Date of Pumping 03/09/2018 2. Quanti Pumped: 1000.0000 Datery p Gallons 3. Component: ❑Cesspool(s) ©Septic Tank ❑Tight Tank n Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes © No If yes,was it cleaned? n Yes ❑ No 5. Observed condition of component pumped: Normal—water1avo1tin bnt'fnm sl a, top snrftic Mafh 11no clear me f, lter_ I PL Lem. au the Lenk, ccu uL Leuk 1, uuL dLsiyned Lu bL used' wiLu. d filLur. Cover(s) secured. Removed wipes and rags . 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 80C, Hartford 03/09/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date tsform4.tloc•11/12 System Pumping Record•Page 1 of 1