2-25-10 Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Kernworxi Country Club Kernwood Country Club
1 Kernwood St 1 Kernwood St
Salem, MA, 019/0 Salem, IVA, 01970
(9�B� -745-1211 x (9781-745-7289 x
Jahn Eagleeton
Type: Emergent Routine ////��
Cesspool: No Yes `�Fpiic�Ta k: No Yes
Date of Pumping: c� Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
r
Contents Disposed at:
S.E.S.D.
Salem, MA.
Date: Pumper Signatur
Condition of System/Other Comments
® Primed onrecydMpeper Dep Approved Form-12/07/95