10 CEDARCREST ROAD SYSTEM PUMPING RECORD 4-30-24Commonwealth of Massachusetts
City/Town of
System Pumping Record
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.
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1
A. Facility Information
1. System Location:
Address
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town 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 Grease Trap
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:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
10 Cedarcrest Road
MA 01970
Janine Pare
10 Cedarcrest Road
01970Salem
9785487849
MA
04/30/2024 1000.0000
System Operating Fine. Normal water level. Heavy top solids. Heavy bottom sludge.
Main line Clear. No filter is present on the tank; current tank is not designed to
be used with a filter. Cover(s) secured. Recommended No Recommendation. Recommend
using boost next pumping.
Michael Graham
NENO Yard: 163 Western Ave, Gloucester, MA 01930
04/30/2024
Salem
Salem
Michael Graham