6 CEDARCREST ROAD - SYSTEM PUMPING RECORDS RECEIVED 09/21/2016 12:22PM 9787450343 Salem Health Dept
09/21/2016 12:16 9782814869 WINDRIVER PAGE 02/02
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Commonwealth of Massachusetts Form 4--System Pumping Record 41%
Massachusetts
System Pumping Record
System Owner System Location
n4eia Roland PLlzu�',rc :fors=:,
6 Cedar Crest Road 6 Cr_'a,t
Salem, IQf ' 01971) Salem, MA C1?iG
.'9788)-745-1019 x (978)-79F1•-1i11;. s
Dian Y,�7lrnd
Type: Emergen Routine
Cesspool: No t„i Yes Septic Tank; No Yes�l�-
Date of Pumping: o5 3a. G Quantity pumped:-/S-C'10 Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
a `1
Date: Pumper Signature:
Condition of System/Other Comments
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Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Dion Roland Primary Rome
6 Cedar Crest Road 6 Cedar Creat Road
Salem, MA, 01970 Salem, MA, 01970
(978)-795-1019 x (978)-745-1019 x
Dion Roland
Typel Emergent Routine
cesspool: Na Yes Septic Tank: No LI Yes��
Date of pumping: Quantity Pumped. /$�-Gy Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
r ,
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments ®�
IPW*k MA.
® Praieionrzgc�Mpaper Dep Approved Form-12/07/95
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Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
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System Owner stem Location -
Y Y
Dion troland Primary Home
b Cedax Crest Road b Cedar Crest Road
Salem, MA, 01970 Salem, MA, 01970
(978)-745-1014 x (978)-74'a-1014 x
Dion Roland
Type: Emergent Routine
Cesspool: Nog Yes Septic Tank: No Yes
Date of Pumping: — —0V Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLL Permit#:
Contents Transferred to:
Contents Disposed at: _
Date: Pumper Signature: < v v
Condition of System/Other Comments
Dep Approved Form-12/07/95
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Ct rY OF SALEM
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Form 4 -- System Pumping Record
Commonwealth of Alassachusetss
AAassachusetts
System Pumping Record
System Owner System Location
cion Roland Ptimtry Home
6 Cedar crept ReAd G Cedatcrest Read
Salem, MA, O1970 Salem, MH, 01970
(v78t -745-101.4 x (978) -745-014 x
Type: Emergency Routine v
Cesspool: w ✓ Yes Septic tank: tJo =Yes
Date of Pumping: (fp So I V LO 0 Quin"Pumped: l$Oo Gallons
System Pumped By: Kind RAA Enwwsnenta/, LLC Permit M
Contents transferred to:
Contents Disposed at:
Isk
$ l�
Date: Pumper Signature: 6.$1
Condition of System/Other Continents
Dep Approved Form - 12/07/95