System Pumping Record 4-15-16 RECEIVED 05/18/2016 08:16AM 9787450343 Salem Health Dept
05/18/2016 08:14 9782814869 WINDRIVER PAGE 04/05
n-�rnr�sna a 07/2712310
Commonwealth of Massachusetts Form 4--System Pumping Record 120%
Massachusetts
System Pumping Record RECEIVED
MAY 18 2016
System Owner System Location
Y ti;=U_EM
Lows11 Susan Ptiml-'y Some o�jAHU OF HEALTH
2 awlan Street i Wyman Street
?=m, Mla, 1119'r0 Sala%, AIA, 0:1970
,973)•-430•-9750 x (97S)-430-9750' x
Lowe II
Type: EmergeneL I Routine
cesspool;' No yes Septic Tank:
No Yes
Dote of Pumping: �*'62 Quantity Pumped:_Gallons
System Pumped By, Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
rwwTp
IPwich, MA,
Dep Approved Form-12/07/95