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System Pumping Record 7-14-15
06!05/2015 13: 43 9782814869 WINr.RIVEP PAGE 03/03 i Commonwealth of Massachusetts Form 4--System Pumping aecord Massachusetts 5 System Pumping Record System Owner System Location 411 :i.a.l`c1'0:'.'CE $t':_r.. . 411 LaLu�'e'U 1 S-nlsm, ;+'lzir X1970 Salem, 'Va, U1,970 Type: emergen Routine - Cesspool: No Yes Septic Tank: No 4 yes Date of Pumping: Quantity Pumped: g5 � _Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to; 1.. Contents Disposed at: B.S.D. Satan.MA. Date: Pumper Signature: Cond7fion of System/Other Comments Dep Approved Form-12/07/95