12-13-11 �.a,nr,rar+.•
Commonwealth of Massachusetts Form 4 System Pumping Record MIM
Massachusetts
System Pumping Record
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'System Owner System Location
'xt�rzs noci coL't71:rCy club Zet4 T11dc &l C:Uvmtry Cl'yb
573.7..1Rk1, IAA., 01070 SiA�.em, PAA, 01$,70 „
Type; Emergenc Routine 9500
Cesspool: No I Yes 5eptic Tank: No Yes
Date of Pumping: Quantity Pumped: Gallons
system Pumped By: Wind River Environmental,LLC Permit#;
Contents Transferred to.
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Contents Disposed at:
READ.
Date: Pumper Signature:
Condition of 5y5tem/Other Comments
® Prmxduor�.ra�aro Dep Approved Form'-12/07/95