System pumping record 6-28-13 07/16/2013 11:42 9782814869 !! WINDRI'JER PAGE 116/00
Commonwealth of Massachusetts Form 4--System Pumping Record . .
Massachusetts
System Pumping Record
system Owner System Location
Kernwaod Caintry Qlub Kernwood. Country Club
1 Ketmgood St 1 Nernwood St
Sal eom, MA, 01910 Salem, MA, 01970 .c4
(979)-745-1210 x (979)-745-7299 x(w 8
John Eggleton 31"7. ' }'
Type: Emergen Routine ( cx .
Cesspool: No Yes ,o"*Tank: No yea„
Dote of Fumpins: t quantity Pumped:pZ-2.Goilons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to; ,
Contents Disposed at:
&E.S D
Salem, N'T 4
Date: __—�a� 1 J Pumper Siytmtaf�` ✓y
Condition of System/Other Comments _..
1
)9 j f,�
Qnnreaq ,«yzmwr� Dep Approved Form-12/07/95