18 WASHINGTON SQUARE WEST SYSTEM PUMPING RECORD 9-27-24 Commonwealth of Massachusetts RECEIVED 2 q S
City/Town of �`W �a ��Yl
Systems Pumping Record OCT 2 s 2024
Form 4 CITY,OF SALEM
BOARD OF HEALTH
D EP 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 fords 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 I. System Location:
on the computer, � j' {�n �n t
use only the tab i 1 I �} L/o �
key to move your Address G�
cursor-do not
use the return
key. City/Town - -- State Zip ode --
2. System Owner:
v� Name —
, , f Address(if different from location)
City/'rown State - - Zip Code
Telephone Number
B. Primping Record
1. Date of Pumping zq 2. Quantity Pumped: - F o d
Date
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Ire se Cl ra�pk-
❑ 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
Wayne's Drains, Inc. _
Company
7. Location where contents were disposed:
Xl
Signature of Mauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5fom14.doc•11/12 System Pumping Record•Page 1 of 1