776 Pump Report 6-7-19 . Commonwealth of Massadhusetts
rz City/Town of Northampton
W System Pumping Record -
:. Forni 4
DEP has provided this form for.use by IocaF Boards. 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 bf Health-to determine the form they use. The System Pumping Record must be submitted:Yo
the local Board of Health*.or other approving authority within 14 da s from the: um In date in
pp 9 Y Y P p� 9
accordance with 310 CMR 15.351:
A: Facility Information : � -
Important:When
filling out forms 1. System tocatiom: -
on the.computer,
use only the,tab 776 North King Street.:'::
.....
to move your Address Northampton MA':. : ._
:cursor-do not .:
use the return: : - — - -
.. - -
key: -City/Town State Zip Code
2.. System Owner:::
Name•:• .. .. :: I :: ::
ILEI _
Address(if different from.location) {
Citylrown State Zip Code
Telephone Number
:: :B: Pumping Record: :'
.. .. .. 6/.7/2019 ..... 1;50.0. . .
1. Date of Pumping 2..Quantity Pum ed:
Date Gallons'.:
3. Component:: , -❑::Cesspool(s) 0 Septic Tank ❑ :Tight Tank:- ❑.Qrease Trap
❑ Other(describe):
.4.:' Effluent Tee Filter.present? Yes:.❑ No If yes, was it cleaned? [.�] Yes ❑. No
5. Observed condition of component.pumped: .:
Ok
6.. System Pumped.By:
Nick.Beausoleil
Name Veh'ideLicensed Number
.... .....
Bostley Sariitary Service, Inc.
.. ..Company .. •• .. ••
7. ::Location where contents were:disposed::: :. .. .. :. ..
Gr nfielcl Wastewater Treatment Plant
.77 6/7/2019
Signature'of Haule ...Date .
-Signature of Receiving Facirity(or attach facility receipt): Date
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