8 CEDARCREST ROAD SYSTEM PUMPING RECORD 10-15-24Commonwealth 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
8 Cedarcrest Road
MA 01970
Nadir Bendjenni
8 Cedarcrest Road
01970Salem
6179438716
MA
10/15/2024 2500.0000
Cover was accessed and properly secured. Septic system serviced. Filter is present
and was cleaned. 2500 gallons removed. Light sludge on bottom of tank. Light top
solids in tank. System is not at proper working level. It is overfull and there is
visible runback from leachfield. Recommend evaluation. Both baffles/tees are
intact. Main line is clear. Recommend using boost next pumping. Adding treatment
Robert Herrick
Ipswich WWTP: 21 Fowlers Lane, Ipswich , MA 01938
10/15/2024
Salem
Salem
Robert Herrick