8-12-10 Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Kernwocd 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: Emergenc Routine 112-- ti
Cesspool: No Yes Scp#icTank: N�o�_^ Yes _
Date of Pumping: R– / 2 —�r] Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to: f
Contents Disposed at: � VVED
SEP 13 2010
S.F S n-
I,LEM
raALTM Salem MA. I
Date: Pumper Signature:
Condition of System/Other Comments
® Nntcdonmc Iedpaper Dep Approved Form-12/07/95