11-30-09 P
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Kernwood Country Club Kernwood Country Club
1 Kernwoocl St 1 Kernwood St
Salem, MA, U19'10 Salem, MA, 01970
(978)-745-1110 x (978'-745-7289 r.
John Eauleston
Type: Emergent Routine lff�
Cesspool: No Yes ank: No Yes�—
Date of Pumping: 1 ( Quantity Pumped:a Gallons
System Pumped By: WindRiverEnvironmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
S.E.S.D.
SW RIIA
g r
Date: Pumper Signotu e.
Condition of System/Other Comme s
JAN 1 12010
-
Dep Approved Form-12/07/95