11 VINNIN STREET SYSTEM PUMPING RECORD 10-29-24 (002)Commonwealth 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
11 Vinnin Street,
MA 01970
Therapy for Intentional Living Inc
50 Jersey Street,
01945Marblehead
7817324161 x
MA
10/29/2024 1000.0000
Cover was accessed and properly secured. Cesspool system serviced. Filter not
present. Tank cannot be outfitted with filter. 1000 gallons removed. 6 inches of
bottom sludge. 4 inches of top solids. System is at proper working level. Both
baffles/tees are intact. Main line is clear. Recommend using boost next pumping.
Michael Graham
Gloucester WPCF: 50 Essex Avenue, Gloucester, MA 01930
10/29/2024
Salem
Salem
Michael Graham