181 FORT AVENUE SYSTEM PUMPING RECORD 6-23-25Commonwealth 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
181 Fort Avenue
MA 01970
Holy Cow Ice Cream Cafe
80 Pleasant Street
01930Gloucester
7819104195
MA
06/23/2025 100.0000
3 Bay Sink. 2 inches of grease on top. 10 inches of water. 2 inches of bottom
sludge. 30 gallons removed. Both baffles/tees are intact. Gasket is in bad
condition - Recommend replacing gasket. Grease trap needs 1 bolt replaced.
Walls/bottom of trap in good condition. System is at proper working level. Left 0
bottles of drain master. BOH Logs Signed. Customer turn away 6/17/2025
Steven Dominguez
Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780
06/23/2025
Salem
Salem