43 CHURCH STREET SYSTEM PUMPING RECORD 1-11-23 Commonwealth of Massachusetts
r- City/Town/Town of: �,•- APR 2 5 2023
Y
System Pumping Record CITY OFSALEM
rp. Forma 4 BOARD OF HEALTH (� V
DEP has provided this form for use by local Boards of Health. Other forms may .
information must be substantially'the same as that provided here. Before using
local Board of Health to determine the form they use. The System Pumping Rec_
the local Board of Health or other approving authority within 14 days from the p, ,
accordance with 310 CMR 15.351.
A. Facility Information
Important:when
filling out forms 1. System Location: /I �,�'^
on the computer, 43 �CU CK\ "��-l}—
use only the tab
key move your Address ���_�,,,r��
cursor-do not • •••-� �y 1 �
use the return City/Town State Zip Code
key.
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2. System Owner: Tr,,^ , is
Name
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Address(if different from location)
CityTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank )Xyl Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
d
6. System Pumped By:
NO
Name V Vehicle License Number
Wayne's Drains, Inc.
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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