18 WASHINGTON SQUARE WEST SYSTEM PUMPING RECORD 10-13-25 Common wealth_of Massachusetts RECEIVED
6 City/Town of 5( �� �,��r 2�
°1 ny stem Pumping Record JAN Q 2026
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
filling out forms 1. System Location:
on the computer,
use only the tab `
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
s ( '�-A)00V
Name
r.:3a
Address(if different from location)
City/Town state Zip Code
Telephone Number
B. Pumping Record
l� ►3 � Z� i � 1�
1. Date of Pumping Date 2, Quantity Pumped: Gallons ..
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank 42�g � rap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
O,C- Cc'�
6, System Pumped By:
z
Name Vehicle License Number
Wayne's Drains, Inc.
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facllit (or attach facility receipt) Date
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