5-20-08 Win. nn.mn.orn nKMNMMIn
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Kernwood Country Club Kernwood Country Club
1 Kernwood St 1 Kernwood $t
Salem, KA, 01970 Salem, KA, 01970
(978)-745-1210 x (978)-745-7289 x
Lean
Type: Emergenc Routine �O
Cesspool: No 1�0 Yes Septic Tank: No Yes
Date of Pumping: 5- ,p?' Quantity Pumped:A�o Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Salem, MA. . . "
Date: Pumper Signature: / � 7>✓
Condition of System/Other Comments
RECEIVED
CITY OF SALEM
BOARD OF HEALTH
Dep Approved Form-12/07/95