118 WASHINGTON STREET SYSTEM PUMPING RECORD 8-26-26Commonwealth 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
118 Washington Street
MA 01970
Rocket Tot Enterprises dba Flying Saucer Pizza Company - IG - Flying Saucer Pizza
118 Washington Street
01970Salem
3303102048
MA
08/26/2026 20.0000
There is a safety concern onsite that needs immediate follow up!. Cover was accessed and
properly secured. Basement. 4 inches of grease on top. 4 inches of water. 4 inches of bottom
sludge. FOG 67%. 25 gallons removed. Inlet baffle/tee is intact - outlet baffle/tee is not
intact. Recommend outlet repair. Gasket is in good condition. Grease trap needs 1 bolt
replaced. Walls/bottom of trap in good condition. System is at proper working level. Left 0
bottles of drain master. BOH Logs Signed.
Quincy Hubbard
Holbrook WRE Yard: 24 South Street, Holbrook, MA 02343
08/26/2026
Salem
Salem
Quincy Hubbard