18 WASHINGTON SQUARE WEST SYSTEM PUMPING RECORD 11-10-25 i
Commonwealth of Massachusetts -7
L System Pumping Becond
Form 4
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 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 t�[
accordance with 310 CMR 15,351.• R CO*%
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A. Facility Information JAN 0 7 20261
Important:When
tilling out forms I. System Location: CITY OF SALEM I
on the computer, c� I BOARD OF HEALTH
use only the tab i7 ,�1 �V ��
key to move your Address --—
cursor- not
use the return
urn key, City/Tvwrii 1 State Zip` ` Zip Code
2. System Owner;
Name
Address(if different from location)
C Iyfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat—e 2. Quantity Pumped: Gallons
scce
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank tease Trap
0 Other(describe):
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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, System Pumped By:
Name 1 Vehicle License Number
Wayne's Drains, Inc.
Company j
7. Location where contents were disposed:
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Signature of Hauler Date
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Signature of Receiving Facility(or attach facility receipt) Date
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