18 WASHINGTON SQUARE WEST SYSTEM PUMPING RECORD (NO DATE) RCV'D 1-3-25 Commonwealth of Massachusetts RECEIVED
5
F Gfty/Town of J" 2- � 3
` S�senn Pumping Record JAN 0 3 2025
Form 4
CI p O HEALTH
DEP has provided this form for use by local Boards of Heali�l9��ierforms may be used, but the
information must be substantially the same as that provided here.Before using this form, check with your
focal 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.,
A. Facility information
Important:when
filling out forms 1 r System Location: (1�use
the computer,
us e only the tab
key to move your Address
cursor-do not SCLQ ArY)
use return key. CWTown State .1 Zip Code
key.
2. System Owner:
': Name
Address(if different from location)
i
i CitylTown state Zip Code
z
Telephone Number
B Pumping Record
1. ` Date of Pumping Date 2. Quantity Pumped: —
Gallons
I n 5
3. Component: 7 Cesspool(s) ❑ Septic Tank ❑ 7ight 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:
CJL
6. ;;System Pumped By:
!'Name vehicle license Number
Mayne`s Drains, Inc.
'Company
7. ;Location where contents were disposed,
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Data
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