18 WASHINGTON SQUARE WEST SYSTEM PUMPING RECORD 12-15-25 Commonw' e7Ith of MaSSaChUSettS RECEIVED z
C�ty/Town df, h'�
FEB 112026
System Pumping Record
c Form 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 fbrro, 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 authorifi,/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 _ I `� �A n G)Y 1 l 1� ��1 )1n Ci C� Ii f ; `fit
key to move your Address
cursor-do not _ ( ��l Or
K'
' use the retut'n
key, city/Town State - -
Zip Code
2. System Owner
nr Name -- ----
Address(If different from location)
City/rown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date2 1 S Z S2 Quantity Pumped: --
Gal)ons.
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank 7 �re`a;e>Yr`{p - -
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was-it cleaned? ' ❑ Yes ❑ No
5. Observed condition of component pumped:
6, System Pumped By:
Name �— Vehicle License Number
Wayne's Drains, rnc.
company
7, Locution where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facllily(or attach facility receipt) Date