9-6-02 • - - Form 4 -- sPung-1R�c�
Comrronwwktt
h of Massachuses � +
: Massachusetts
System P'r'am"Record SEP 2 32002
CITY OF SALEM
BOARD OF HEALTH
Sys en owner system location
Kernwood Country Club Dean Kernwood Cowitry Club
I Kernwood St 1 Kernwood St
Salem, 14A. 0.1970 `a Salam. KA 01970
(978)-745 -7289 x (9 .8)-745-7299 x
pan
Type: Emergency Martine
Cesspool: No � ) Yes $split tank: No ��Yes
Date of pumping: Quantity Pumped /7�Gj—kq ( /Gallons
System Pumped By: Wird IPivrr Environmental, LLC permit#:
Contents transferred to:
Contents Disposed at:
117
Date: Pumper'Sl9mture:
Condition of Sy Other Comments
Dep Approved Form - 12/07/95