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811 Pump Report 2018 (5) Commonwealth of Massachusetts City/Town of Northampton UP E System Pumping Record UPS 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 Kiriq 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 02993 City/Town State Zip Code 6179737235 xnis _ Telephone Number B. Pumping Record 07/10/20181000.0000 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: fl Cesspool(s) ©Septic Tank Tight Tank D Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes© No If yes,was it cleaned? D Yes ❑ No 5. Observed condition of component pumped: 11:.gC—watt. r nen; Bin hnff„m-syudge 1'w top net_'en mate r No f:lfar •s— plea ere_ ire the tank, LUL re'L Lank in uuL deniy'id w be usrid wire d ril Len. Cover(s) secured. System Evaluatrcn recommended . Repairs needed: Pump chamber not working ,sewage all over ground when I got here, . 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 07/10/2018 Signature of Hauler Date Signature of Receiving Fadlity(or attach facility receipt) Date t5form4 doc•11(12 System Pumping Record•Page 1 of 1