43 CHURCH STREET SYSTEM PUMPING RECORD 10-16-24 Commonwealth of Massachusetts
City/Town of
ystem Pumping Record
Form 44
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.. _RECEIVED
A. Facility information DEC 2.4 2024
Important.When
filling out forms 1: System Loc`atiioonn:on the computer, t^ 1
ALEM
use only the tab \'1 :J _� \\/�`f (-,h BOARD CITY OFF EA TH
key to move your Address
cursor-do not S' C•
use theretum Citylrovm State
key. —! Zip Code
2, System Owner.
game
Address(If drferent from location)
CiVTown 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 � �Pe I rap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ .No If yes, was it cleaned? ❑ Yes ❑ No
6. ! Observed condition of component pumped:
aC,Cd
6. System Pumped By:
T�c �r
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
t5form4.doc-11/12 System Pumping Record• Page 1 of 1