10-23-09 i
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Kernwood Country Club Maintenance Building
1 Kernwood St 1 Kernwor)d St
Salem, MA, 01970 Salem, MA, 01970
(978)-745-1-'10 x (978)-745-1210 x
Kernwood Country Club
Type: Emergent Routine -
Cesspool: No Yes Septic Tank: No F—I Yes
Date of Pumping: Quantity Pumped: 8000 Gallons
System Pumped By: Wind River Environmental,LLL Permit#:
Contents Transferred to:
Contents Disposed at:
`�-E S 61,
Salem, MA.
Date: Pumper Signature:
Condition of System/Other Comments
i
7
® Primdon,zgd,dr.,, Dep Approved Form-12/07/95