12-7-06 U4220114037, 0"VM
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
KernwocA Country Club Kernwood Country Club
1 Kernwood St 1 Kernwood St
Salem, MA, 01970 Salem, MA, 01970
19183 -735-1210 x (97EI)-745-7289 x
Lenn
Type: Emergent Routine
Cesspool: No Yes 2N,= Yes=
Date of Pumping: Quantity Pumped:,�2 1SUJ Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
S i
Date: I Pumper Signature:
Condition of System/Other Comments
RECEIVED
'JAN " 52001
I
BOARD OF HEALTH
Dep Approved Form- 12/07/95