352 LAFAYETTE STREET SYSTEM PUMPING RECORD 7-17-26Commonwealth 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
352 Lafayette Street
MA 01970
Citywright - OS - Salem State
100 Weymouth Street
02370Rockland
7819138325
MA
07/17/2026 1000.0000
Cover was accessed and properly secured. Tight Tank system serviced. Unable to access outlet
of tank to check for filter. 1000 gallons removed. 1 inches of bottom sludge. 0 inches of top
solids. System is at proper working level. Unable to test main line.
Jonathon Colson
NENO Yard: 163 Western Ave, Gloucester, MA 01930
07/17/2026
Salem
Salem
Jonathon Colson