12 RIVERVIEW STREET CS�rIc�
ROOTER-MAN FORM 4 - SYSTVVI PUMPING RECORD
P. 0. BOX 471
PEABODY, MA 01980
Commonwealth of Massachusetts RPM��
Massachusetts
APR 2 2 1998 .
CITY OF SALEM
HEALTH DEPT.
System Pumpia Record
System Owner System Location
Date of Pumping: Quantity Pum ed• V
gallons
Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes Lam"
System Pumped by:_ 4t/1.1.u. .` .r (�! ............. License #: .................................. .... __..
Contents transferred to:
Date Inspector
4
• � t
• 1