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Commonwealth of Massachusetts Form 4--SystemPumping Record,a�0 1,
Massachusetts
System Pumping Record
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System Owner System Locotion
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Type: Emergen Routinef'�
Cesspool: No Yes 4epf+rTdnk: No Yes
Date of Pumping: (.�`/ Quantity Pumped: OQO Gallons
System Pumped By:, Wind River Environmental,LLC _ Permit M 1!
Contents Transferred to:
Contents Disposed at: y ?,J).
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Date: Pumper Signature:
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Condition of System/Other Comments
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® r,ivaaun�ecydalpaac Dep Approved'Form 12/07/95