3-21-07 0222015044 WotY1iW0
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, 0197U
(978)-795-1210 x (978)-74b-7289 x
Dean
Type: Emergenc Routine
Cesspool: No Yes ' Tank: No Yes
Date of Pumping: � $e/L
TQuantity Pumped: O O Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
-Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
RECEIVED
'APR -5 2001
CITY OF SAI-EM
BOARD QF iFjF4TH
Dep Approved Form-12/07/95