6-11-07 05/01/2000
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 St
Salem, MA, 01970 Salem, MA, 01970
(978)-745-1210 x (978)-745-7289 x
Dean
Type: Emergent Routine ?.t
Cesspool: No Yes SepTrrrank: No Yes
Date of Pumping: Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC - Permit#:
Contents Transferred to:
Contents Disposed at:
S.D.
Salem, Ani
Date: Pumper Sig4ure: Z4
Condition of System/Other Comments
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UIiY �:� Si;L E^A
�E �,`y n� HEALTH
Dep Approved Form-12/07/95