System pumping record 6-2-11 Commonwealth of Massachusetts Form 4—System Pumping Record
Mosso6husetts
System Pumping Record
System Owner System Location
ncl:v
5,
K�, V11401.
n7,, 7 401,
IFkSs
t
NO;)
Type: Ernergen Rout"Ic
Cesspool: No Yes es Siptic Tank: No Yes
Date of Pumping: (0—.%- t Quantity Pumped; 19-06, Gallons
System Pumped By; Wind River Environmental,LLC Permit
Contents Transferred To:
I 1t
Contents Disposed at;
II
Date: Pumper Signature"
Condition of System/Other Comments
li
III
Dep Appraved Form-12/07/95