43 CHURCH STREET SYSTEM PUMPING RECORD 9-18-25 i
GommonWealth of Massachusetts RECEIVED
City/Town of..- 5CLk�,Vv-) DEC 0 4 2025
System Pumping Becord
FOrrrt 4 CITY OF SALEM ;
F 'w_ BOARD OF HEALTH
'I
DER 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 Vivith 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 I
accordance with 310 CMR 15,351.,
A. Facility Information
Important:When
Tilling out forms I. System Location: �
on the computer,
use only the tab
key to move your Address
cursor-do not �� �f �n
use the return ti t�
key. CivTown State
Zip Code i
2. System Owner;
Name
Address(if different from location)
i
Crtyfrown State Zip Code
Telephone Number l
B. Pumping Record
i $
Date of Pumping IZSDate 2. Quantity Pumped: G
Gallons I
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease T p
i
0 Other(describe): '
' I
4.. EfF[uent.Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No I
i
5. Observed condition of component pumped:
c4onri
i
e, System Pumped By:
i
Name Vehicle License Number
Wayne's Drains, Inc.
Company
7. Location where contents were disposed:
bbU— n
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date