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CVRRIER
SEPTIC & D FORM 4-SYSTEM PUMPI1.16 RECORD
SERVICE
107 FOR STREET; MIDDLETONN, IVI
(978) 774-2772 MA 01949
p9l,
11Vf0
2 4 2000
COMMONWEA CITY OF SALEM
0 LTH OF MASSACHUSETTS , HEALTH DEPT.
-MASSACHUSETTS
SYSTEt1 PUMPING SCO
RD
SYSTEM OWNER:
` v1 A c Ke L SYSTEM LOCATION:
ATE OF PUMPING: Ap�O
QUANTITY PUMPED:
ESSPOOL:' NO �/ GALLONS
L9 YES SEPTIC TANK: NO
STEM PUMPED BY: YES
CUR No
SEPTIC & D
NTENTS T _ RAIN SERVICE
RANSFERRED T0: S� S��
INSPECTOR:
C
RooTER-MAN 11 FORM 4 + SYSTEM PUNEPI1NG RECORD
� PEABODYB MA401980
o
Commonwealth of Massachusetts APR 2 2 1998
Massachusetts CITY OF SALEM'
HEALTH DEPT.
System Pumping Record
System Owner ---System Location
Date of Pumping:/ j/y� / Quantity Pumped:/,5��gallons
Cesspool: No Yes ❑ Septic Tank: No Yes —1
System Pumped by:.. . License / v
� � #: ............ .................... .. .
.. ............. . .
Contents transferred to:
Date '�� " Inspetdr
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