5-28-07 0222016702 05l01I2000
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
5ystexmeonierc+od Country Club Syslte1mULocotiorhnck Bar - Kernwood C.C.
1 Kernwood St 1 Kernwood St
Salem, MA, 01970 Salem, MA, 01970
(978)-745-1210 x (978)-745-7289 x
Dean
Type: Emergency RoutineA—�
Cesspool: No Yes Septic Tank: *10
Yes
Date of Pumping: pe��,7{,(b� Quantity PumGallons
kkkkkk �
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date: 's-kilo-7 Pumper Signature:
Condition of System/Other Comments
RECEIVED
'JUL 0 9 2001
,I O "V-=_?,+
Dep Approved Form-12/07/95