18 WASHINGTON SQUARE WEST SYSTEM PUMPING RECORD 1-22-26 r '
DECEIVED
Commonwealth of Massachusetts
9� -(i; City/Town of �`� _ ���m it MAR 13 2026
System Pumping Record
" ICITY OF SALEM
Form. ARD 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 fine 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
A. Facility information �
Important:When
filling out forms 1. System Location: !
on the computer, i
use only the tab ,(-?b� ` "Fri (A ),a
key to move your Address
cursor-do not
use the return K C' !Town _
key. ` State �I Zip code
2. System Owner
l zj j�j d. on
Name
Address(if different from location) it
li li
GtEjr!town state i' Zip Coale
i' Telephdne Number
B. Pumping Record
1. Date of Pumping Zz 2. Quantity Pumped: 'Uo
Date ;I Gallo CAP
ns'
3. Component: ❑ Cesspool(s) ❑ Septic Tank [I Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No P If yes,yvas it cleaned? ❑ Yes ;❑ No
a
e
5. Observed condition of component pumped: i
200
i
6. System Pumped By:
D a vL-' i Pt Ann-
- Js
Name � Vehicle License Number
Wayne's Drains, Inc. ? '
Compa:iy
7. Location where contents were disposed:
i
Signature bf Hauler Date
Signature of Receiving Facifity(or attach facility receipt) Date
. . I