9-13-06 Commonwealth of Massachusetts Form 4--System Pumping_Record
Massachusetts
System Pumping Record
System Owner System Location
. .swelb'
nernwocd Country Club Kc)rnwo d Country Club
1 Kernwood St 1 .4!;,L4crex4 2t-
Salem, MA, 01970 Salem, MA, 01970
1976) -745-1210 x (976)-745-7299 x
n.An
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yesd
Date of Pumping: - Quantity Pumped:,?L Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature'.
Condition of System/Other Comments
Dep Approved Form-.12/07/95