System pumping record 4-25-16 RECEIVED 05/18/2016 08:16AM 9787450343 Salem Health Dept
05/18/2016 08:14 9782614869 WINDRIVER PAGE 05/05
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Commonwealth of Massachusetts Form 4--System Pumping Reoordl266°A
Massachusetts
System Pumping Record
RECEIVED
System owner System Location
xernwood Country Club Aernwood Country Club 6ALEM
i Aerawood Street l xernwro 4 Street "JNNiJ OF NEgl j
Salem, MA, 01970 5s:cem, MA, 01970
(978)-745-1210 x (978)• 745-7289 %
Jriar. laggleston
Type: emergen Roatine
cesspool: No Yes Septic Tank: No = Yes
Date of Pumping: �'/;L/e - Quantity pumped: 200- 660ons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to;
a
Contents Disposed at:
Date: ._ Pumper Signature:
londition of System/other Comments
4
S
i
I� aoweeonarydmso�n Dep Approved Form-12/07!95