System pumping record 12-21-15 02/12/2016 15:06 9782814865 6JINDRIVER PACE 07/14
020 r06fl239 Gslasr000
6.7568
Commonwealth of Massachusetts Form 4-•System Pumping Record
Massachusetts
System Pumping Record a
System Owner System Location
,Kernwood Country Club Maintenenee Building
1 Kernwood Street 1 Kernwood Street
Salem, MA, 01470 Salem, MA, 01910
(978)-745-1210 x (978)-745-1210 x
nernwood Country Club
Type; Emergen Routine
Cesspool: No Yes Septic Tank: No Yes=
bate of Pumping: 2 - ( — I Sr Quantity Pumped: /$2U Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: �y�
+'Y -`w
bate: 1�` � Pumper Signature:
Condition of 5ystem/Other Comments
® ermW o�m=r���onper Dep Approved Form-12/07/95