1 ELEANOR ROAD SYSTEM PUMPING RECORD 10-2-25 i
Commonwealth of MassachusettsRECEIVED
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System Pumping record
JAN 0 5 2026
f Form 4 CITY OF SALEM
+ BOARD OF HEALTH
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..
A. Facility Information
Important:When
on the
out forms 1. System Location:
on the computer, Y C�
use only the tab O
key to move your Address
cursor-do not
use the return ~~
key. C�ylrovJn State Zip Code
2. System Owner, �? j
Name
Address(if different from location)
CWTown State Zip Code
Telephone Number .l
B. Pumping Record
t �a aS i Wo
1. Date of Pumping Date 2. Quantity Pumped:
Gallons I
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Tiap
❑ Other(describe):
4.. Effluent'.Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No I
5. Observed condition of component pumped:
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6
6, System Pumped By: ?
Name Vehicle License Number
Wayne`s Drains, Inc.
Company
7. Location where contents were disposed:
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Signature of Hauler Date
Signature of Receiving Facliily(or attach facility receipt) Date
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