412 LAFAYETTE ST i
MMt171NM
Commonwealth of Massachusetts Form a--System Pumping
Massachusetts 1'��
System Pumping Record e
System Owner System Location
Vav,judes Joanie Primary Home
91 ' Lafayette Stxee
414' Lafayette Street.
Salem, 11A, 0!970-- -- Salem, MA, 01970
04790 '745-5318 x (978)-795-5318 x
Vavoudes
Type: Emergent Routine
Cesspool: No Yes Septic Tank: . NoYes _
Date of Pumping: quantity Pumped:--,:y allons
— i;�dSystem Pumped By: Wind Iver Environmental,LLC Permit#:
Contents Transferred to: ,
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
V
SEP 13, 2006
CITY OF SALEM
BOARD O
Dep Approved Form-12/07/95