18 WASHINGTON SQUARE WEST SYSTEM PUMPING RECORD 2-18-25 ECEIVE6
Commonwealth of Massachus6tts
City/Town df-.--:L' 6W APR 0 12025 System Pumping Record
CITY OF SALEM
si Form 4 I OARD OF HEALTH
DEP has provided this form for use by local Board of Health,10therformi maybe used, but the
information must be substantially the same as thd provided h6re. Before using this f6rM, 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 autho:Ht ywithin I days from the pumping date in
accordance with 310 CMR 15.351..
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab Lzo, ';h
key to move your Address
cumor-do not
use the return a rO i('*
key. City/Town
State it 7-1p Code
2. System Owner".
Name
Address(if different from location)
i II
CWrown State !zip Code
-feleph6ha Number
B. Pumping Record
1. Date of Pumping 2 1 2. Quantiq'- Pumped: 00
Date 'Gallons
3. Component: ❑ Cesspool(s) El Septic Tank [I 'right Tan'k
eGraSe I rep
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,yeas It cleaned? M Yes F-1 No
5. Observed condition of component pumped:
G-C\
6. System Pumped By,
U LP
Name Vehicle license Num er
Wayne's Drains, Inc.
Company
7. Location where contents were disposed:
(k vie
Signature of Hauler Date
-
Signature of Receiving Facifty(or attach facility receipt)
pate