6-28-11 P I
Commonwealth of Massachuse"s .. Form 4--System Pumping Record
Massochusetts
System Pumping Record
System Owner System Location
'Salem, MA, O _��'M
:e•��ar...'i�1E•.1.a:'i.'1 ?< i1?78'It-7A5- 728<: x
Type: Emerge Routine
Cesspool: No Yes Sept Tank: No yes'Y�
Date of Pumping: �!� Quantity Pumped: W71C Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
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Contents Disposed at:
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Date: Pumper Signature:
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Condition of System/Other Comments
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® v,nnammcycleawP- Dep Approved Form-12/07/95