SYSTEM PUMPING RECORD 9-18-15 10/15/2015 12: 43 9722614865 WINDRIVER PAGE 02/02
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Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Luxury Loo Sob site
86 tats Haysn Road 32 Charter Street.
NattaD. oisett, NA, 02139 salem, MA, 01970
(860)-639-8214 x (860)-639-8214 x
Luxury Loo
Type: :Emergeh Routine /
Cesspool: Yes Date of pumpingr-- Septic Tank: No Yes
Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
SII Contents Transferred to:
Contents Disposed at:
_. SMkan,
)aTe: P Y 5 Pumper Signature:
:ondition of system/o-ther Comments
V PdnrcJonmc W pap r Oep„Approved Form-12/07/95