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811 Pump Report 2018 (3) Commonwealth of Massachusetts City/Town of Northampton System Pumping Record L‘ 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: 811 North King Street. Address Northampton MA 01060 City/Town State Zip Code 2. System Owner: Mass DOT —Name 668 South Avenue Address(if different from location) Weston MA 02493 City/Town State Zip Code 6179737235 xnis Telephone Number B. Pumping Record 07/24/2018 1000.0000 1. Date of Pumping Date 2. Quantity Pumped: canons 3. Component: 0 Cesspool(s) ©Septic Tank 0 Tight Tank ❑Grease Trap 0 Other(describe): 4. Effluent Tee Filter present? ❑Yes © No If yes,was it cleaned? ❑Yes ❑ No 5. Observed condition of component pumped: 4iigh ate-r--.Leverfli herr^m Rlu4Qe-- rill', top-sa1id Maitlline C1r3Ond nin f'1tar I, presuM_ on -Le Ldnk, LUL L2uL lank 1 uuLvusiyr12tt ne wad wYiirttl Lc. Cover(s) secured. Repairs needed: Pump repair needed. Pump chamber. . Pump is not work. 6. System Pumped By: Andrew Ferrier Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: WWTF Palmer: 1 Norbeil Street, Three Rivers, MA 01060 a' 07/24/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt Date t5torm4 doc•11/12 System Pumping Record•Page 1 of 1