20 FRONT STREET SYSTEM PUMPING RECORD 9-29-26Commonwealth 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
20 Front Street
MA 01970
Wolf Next Door Coffee - IG - Front Street Coffeehouse
142 Derby Street
01970Salem
5084230052
MA
09/29/2026 20.0000
Cover was accessed and properly secured. Basement. 3 inches of grease on top. 8 inches of
water. 3 inches of bottom sludge. FOG 43%. 30 gallons removed. Both baffles/tees are intact.
Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper
working level. Left 0 bottles of drain master. BOH Logs Signed.
David Patino
Holbrook WRE Yard: 24 South Street, Holbrook, MA 02343
09/29/2026
Salem
Salem
David Patino