43 CHURCH STREET SYSTEM PUMPING RECORD 11-14-23 Commonwealth of Massachusetts
City/Town of �' _ RECEIVED
System Pumping Record 2024
Form 4 FEB 0 5
CITY OF SALEM
DEP has provided this form for use by local Boards of Health. Other forms may be us®CbAWQfe-IEALTH
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 ---
Important:When
filling out forms 1. System Location:
on they the he tab
computer,
use only
key to move your Address ---- — ------
cursor-do not
use the return k CfVTown ----
key. State Zip Code
2. System Owner;
Name CLan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: t C
Gallons ��QQ�
3. Component: ElCesspool(s) ❑ Septic Tank ❑ Tight Tank ( rea '7tapf—
❑ Other(describe): — -- -- -- -- -----
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: � )p
r-k
Name 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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