4-28-08 0222020014 OW12000
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
MAV
System Owner. System Location
Kernw; cd Country Club Kernwo(A Country C'lutg0 f� Op, �B
1 Kernwucd St 1 Kernwood St �D OPEN t>
T/y
Salem, MA, 01970 Salem, MA, 01970
(978) -745-1210 x (978)--745-7289 x
Ek4an
Type: Emergent Routine
G�Y
Cesspool: No Yes titrM
Ta-n; No = Yes
Quantity
Date of Pumping: o Z'1
Pumped:p ?� 0 Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
�y o
Date: Z Pumper Signature:
J
Condition of System/Other Comments
fvr(� t.
Dep Approved Form-12/07/95