System Pumping Record 11-4-13 12/09/2013 11:21 9782814869 WINDRIVER PAGE 11/11
Commonwealth of Massachusetts Form 4--System Pumping Records®%
Massachusetts
5ystem Pumping Record
S Y stemwner " System Location
Zallen Roy Primary Home
1 Eleanor. Rd 1 Eleanor Rd
Salem, MA, 01970 Salem, MA, 01970
(978)-745-0152 x (978)-745-0752 x
Zallen Roy
Type: Emergent Routine
Cesspool: - No Yes li Septic Tank: No YCSD�
Date of Pumping /i/cp�3 quantity Pumped: Gallons
System Pumped 6y: Wind River Environmental,LLC Permit 9
Contents TAensferred to:
ecnttnts Disposed at:
)ate: Pumper Signature: M
:ondltion of System/Other Comments C/
B.S.D.
Salem.MA.
Rmedonrc yds p p Dep Approved Form-12/07/95