System pumping record 11-14-12 12105/2012 11:24 9782814869 WINDRIVER PAGE 02/63
Commonwealth of Massachusetts Form 4-system Pumping Record?254N3fr
Massachusetts
System Pumping Record
System Owner System Lacatigt
Xernwrood Country Cl%ib Xernwoodl Country Club
1 Kernwood SL 1 Xernwooci St
Salem, MA, 01970 Salem, NtA, 01970
(978)-756--1210 x (978)—'145-7299 x
John Eggletton r
Type; Emergent EE— Routine
Cesspool: No Yes EESeptic Tank: No Yes v7
Date of Pumping- Quantity Pumped: 95Y)Calkins
System Pumped 6y: Wind River Environmental,LLC - Permit#;
Contents Transferred to:
Contents Disposed at;
r7-E.S.D
)ate: Pumper signature:
,ondition of System/Other Comments
Dep Approved Form-12/07/95