System pumping record 6-23-20 Commonwealth of Massachusetts
�m City/Town of salem
System Pumping Record
Form 4
DEP has provided this farm for use by local Boards of Health.Other forme t t Is IF t o must be
substantially the same as that provided here.Before using this form,Chet o M Ith Ddetemninetthefrum,
they use.The System Pumping Rewrd must be submitted to the local Se r th r a g a�thonty within 14
days from the pumping date in accordanca with 310 CMR 15.351.
A. Facility Information
1. System Location:
1 Kernwood Street
Address
Salem 0 970
Cityfiown SD Zi ode
2. System Owner:
Kernwood Country Club
Name
I Kernwood Street
Address(if different from location)
Salem 0 970
City/town St
la ZipCade
97 r 8 c u
Tel p
B. Pumping Record
1. Date of Pumping 06/23/2020 2 Qu 2 0.0000
Date Ga Ions
3. Component: Cesspool(s) Septic Ta it it -ar Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes❑X No If N A 1 11 1 at ad'' as No
5. Observed condition of component pumped:
e use wit a r ter. Cover s secure .
6. System Pumped By:
Michael Graham
Name To Ii mi I e r
Wind River Environmental, LLC, 577 Main S t 11 u son MA 01749
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
06 2
Signature of Hauler Dal
Signatureaf Receiving Facility(or attach facility recelpt) Dat
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