157 LAFAYETTE ST 1 5 7 L 19 FAY E TTE s r:
5C"i'C� c
AnnAnnnn�A MH'1HaM
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Fearmunt Realty Fearmont Realty
146 Summer Street 157 Lafayette St
Dancers, MA, 01923 Salem, MA, 01470
(978) -774-4260 x Office (978)-360-9876 x CELL
Sart -
Type: Emergent Routine
Cesspool: No ✓ Yes Septic Tank: No F YesF
Date of Pumping: / Quantity Pumped: 5LA L Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature:
1 -
Condition of `S-ystem/Other Comments la euec� 1.1 t tf 'eco e h me by rm�5 inrn&eU1
U�
lel)ro F60-ec
RECEIVED
FEB 112008
CITY OF SALEM
BOARD OF HEALTH
Dep Approved Form- 12/07/95 J