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811 Pump Report 2018 (4) Commonwealth of Massachusetts City/Town of Northampton a )rn System Pumping Record -_— z 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 Kind 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 07/16/2018 1000.0000 1. Date of Pumping Dam 2. Quantity Pumped: cellons 3. Component: ❑Cesspool(s) © Septic Tank ❑Tight Tank ❑Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑Yes© No If yes,was it cleaned? ❑Yes ❑ No 5. Observed condition of component pumped: Hi,lh W2LES—LE3•ca n;n hnhhnm c ,r_ -n. temp cnji-d5--Rai 1n Nah Lppl;•"h e Np TiiLer la peeseLL un Lilt Lduk, LULrelL Lank is uuL desiyued Lo be uoad w.Lb d kilter. Covers) secured. Serviced lift station. 6. System Pumped By: Scott Brusseau Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: NECS Yard : 34-1 Hatchett Hill Road , Old Lyme, CT 06371 07/16/2018 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4 doc•11/12 System Pumping Record•Page 1 of 1