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Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Spencer Contrncting Jcbsite Spencer Contracting
EO Box B75 417 Lafyette Street
Salem, NSA, 01970 Salem, VIA, 01970
1976)-791-8001) x (976)-654-2471 x
Gary
Type; Emergen Routine
Cesspvvl: No Yes /' .�Ci
Date of Pumping: No Yes�'"—
3 S� quantity Pumped: C1r / Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
S.E.S.D
em_
)ate: Pumper Signature: Sir
,ondition of System/Other Comments 5
OQ
Dep Approved Form-12/07/95