11-22-10 4
Commonwealth of Massachusetts Form 4--System Pumping Record OS
T s , Massachusetts
System Pumping Record
S
System Owner stem Location I'
Y Y
Kernwood Country Club Kernwood Country Club
1 Kernwood St 1 Kernwood St
I 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
Date of Pumping: Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
��1�S�.S.E.S.D.
S1O
Date: Pumpe ignature:
Condition of System/Other Comments
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a'�D JF
® Pnmda.�,deaDep Approved Form-12/07/95