6 CEDARCREST ROAD - SYSTEM PUMPING RECORD 8-23-10 /222032079 0&1412001
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Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
" System Pumping Record
System Owner System Location
Dion Roland Prinary Home
6 Cedar. Crest Road 6 Cedar Crest Road
Salem, MA, 01970 Salem, MA, 01970
(978)-745-1014 x (978)-745-1014 x
Dion Roland
(Type: Emergen Routine -
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: A3- 10 Quantity Pumped:1_15C)2 Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
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Salem, MA.
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Date: Pumper Signature:
Condition of System/Other Comments
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® PdmedanagdI Adj.a, Dep Approved Form-12/07/95