278 DERBY STREET SYSTEM PUMPING RECORD 9-26-25 RECEIVE®
Commonwealth of Massachusetts
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City/Town of So DEC 0 4 2025 (Q 2 Z Z
X System Pumping Record CITY OFSALEM
Form 4 BOARD OF HEALTH
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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 uvith 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 .
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Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor- not
' use the return � rJ
key. City/Town own State Zip Code
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2. System Owner;
vo k -�- I
61 �ar
Name
11-10114
Address(if different from location)
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Cilyrfown state Zip Code
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Telephone Number
B. Pumping Record
1. Date of Pumping Date' 2.2. Quantity Pumped:
Gallons I
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap
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❑ Other(describe):
4.. Efffuent•Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ' ❑ Yes ❑ No
5. Observed condition of component pumped:
ar)n �1
6, System Pumped By:
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lit 1 P:e in I/1 l 1
Name Vehicle Licens umber
Wayne's Drains, Inc.
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Pacllity(or attach facility receipt) Date
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