83 WASHINGTON STREET SYSTEM PUMPING RECORD 9-5-24Commonwealth 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
83 Washington Street
MA 01970
The Juicery
40 State Street
01950Newburyport
6032341223
MA
09/05/2024 100.0000
[Basement]:. Plastic. 10" H2O. 6" SOL. 6" GRS. Gasket OK. BOH logs signed. Extra
Services : . Pumped and cleaning 1x greace trap. Did you check in and out? :
Unchecked. No signature/store stamp.
Thiago Domingos
South essex sewerage district: 50 Fort Ave, Po Box 989, Salem , MA 01970
09/05/2024
Salem
Salem
Thiago Domingos