1 DIPIETRO AVENUE SYSTEM PUMPING RECORD 11-18-24Commonwealth 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
1 Dipietro Avenue,
MA 01970
Susan Spinale
1 Dipietro Avenue,
01970Salem
6177210395 x
MA
11/18/2024 1000.0000
Cover was accessed and properly secured. Cesspool system serviced. Filter not
present. Tank cannot be outfitted with filter. 1000 gallons removed. Light sludge
on bottom of tank. Light top solids in tank. System is at proper working level.
Both baffles/tees are intact. Main line is clear. Recommend using boost next
pumping.
Michael Graham
NENO Yard: 163 Western Ave, Gloucester, MA 01930
11/18/2024
Salem
Salem
Michael Graham