43 CHURCH STREET SYSTEM PUMPING RECORD 2-27-25 Commonwealth of Massachusetts
DECEIVED
ig, City/Town of ��`' S CL k-e.ifvl jjAPR 01 2025
System Pumping Record ITYOFSALEM
-;~ Form 4 I B6 ARE)OF HEALTH
i ;i i •
DEP has provided'this form for use by local Boards of Health,i0ther forms may be used, but the
information must be substantially the same as thai provided Mere. 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 15.3fi7..
A. Facility Information �
Important When
filling out forms I. System Location:
on the computer, 2 ,^ , t,V-
use only the tab �-'� ' ) C y(�d� h : 1--
key to move your Address e
cursor- not 5 C cu ,�,� i I
use the return
or
key. Cchy/Town State Zip Code
2. System Owner, i
i
Name
Address(if different from location)
i;
City/Town Sate Zip Code
i
Telephoe Number
B. Pumping record
I. Date of Pumping Date 2. Quantitw Pumped:
i "I 'Gallons
3. Component: ❑ Cesspool(s) tt
❑ Septic Tank ❑ Tight Tank .� ej�Trap
❑ Other(describe): .I
4. Effluent Tee Filter present? ❑ Yes ❑ Na ;yes, has rt cleaned? ElYes ❑ No
i
5. Observed condition of component pumped: s
(A
6. System Pumped By:
Name Vehicle Ucense Number
Wayne's Drains, Inc.
Company
1
J
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date