10 SALT WALL LANE 5-14-22 SYSTEM PUMPING RECORD (2) .-t-\___� Commonwealth of Massachusetts RECEIVED
City/Town of
JUL 0 5 2022
System Pumping Record
Form 4 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 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 16,361,
A. Facility Information
Important:When
filling out forms 1. System Location;
on the computer, �1 f
use only the tab _ /V 5G 7L
key to move your Address
cursor-do not _�4 Z69A � (
use the return CitylTown State Zip Code
key,
00--Pl 2. System� Owner:
Name
Address(If different from location) �^
City(rown State Zip Code T
2G C;
Telephone Number
B. Pumping Record
1. Date of Pumping Date ' 2. Quantity Pumped: Gallon
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 bate ^�^
Signature of Receiving Facility(or attach facility receipt) Date
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