System pumping record 8-27-15 WINDRI'JER PAGE 02/02
O'9/03/2O15 09:59 9762811869
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I� Commonwealth of Massachusetts Form 4 System Pumping Record%
Massachusetts
System Pumping Record
System Owner System b.ocation '
Iferawood Country Club Kernwood Country Crab
1 Yernvood Street 1 Aernwood Street
Salem, MA, 0 .970 Salem, KA, 019701
(978)-795-1210 x (979)--745-720 x
John Eggleutou
Type: EmergencyRoutineKay—
Cesspool: No Yes ,.:a¢�FfF Tank: No YesHI `
Date of Pumping?i 7 Quantity Pumpee!"a��Gallons
System Pumped By: Wind River Environmental,LLC Permit
=ontents Transferred to: . ,
ontents bisposed at:
rte:
Pumper Signature:
mdition of 5ystem/Other Comments
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Ff�:/:2'jrYfl
Dep Approved Form-12/47/95