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d .. _ Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Barden Tim Primary Home
19 Intervale Road 19 Intervale Road
Salem, MA, 01970 Salem, MA, 01970
(978)-406-5810 x (978)-406-5810 x
Barden
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yes /
Date of Pumping:2-'4 12 Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Salem, MA.
_.. _.
, .
Date: Pumper Signature:
Condition of System/Other Comments
® Prinredonrecycled paper Dep Approved Form-12/07/95
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