23 ENDICOTT STREET SYSTEM PUMPING RECORD 3-19-26Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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.
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1
A. Facility Information
1. System Location:
Address
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
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
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
23 Endicott Street
MA 01970
Salem House of Pizza - IG - Salem House of Pizza
23 Endicott Street
01970Salem
6179554716
MA
03/19/2026 100.0000
Left 0 bottles of drain master. System is at proper working level. Walls/bottom of trap in
good condition. Grease trap needs 1 bolt replaced. Gasket is in bad condition - Recommend
replacing gasket. Both baffles/tees are intact. 35 gallons removed. 3 inches of bottom
sludge. 6 inches of water. 3 inches of grease on top. FOG 50%. 3 Bay Sink. Bolt does not
tighte, gasket tearing. Recommend Drain Cleaning. BOH Logs Signed.
Josh Melendy
Inside Grease - NEMO Yard: 54 Knox Trail, Acton, MA 01720
03/19/2026
Salem
Salem
Liam Brown