3-28-11 Commonwealth of Massachusetts Form 4--System Pumping Record 0%
Massachusetts
System Pumping Record
System Owner """ System Location
Kernwood Country Club Kernwood Country Club
1 Kernwood St 1 Kernwood St
Salem, MA, 01970 Salem, MA, 01970
(978)-745-1210 x (978)-745-7289 x
John Eggleston
Type: Emergent Routine
r
Cesspool: No Yes Tank: No Yes�f
Date of Pumping:3 Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date: Pumper ignature:
Condition of System/Other Comments
MAY 0 4 NAI
OI(Y OF SALEM
BOARD OF HEALTH
® Printed oureryeiedpaper Dep Approved Form-12/07/95