6-4-02 Form 4 -- System Pumping Record
Commonwealth of Massachusetts
' Massachusetts
System Pumoim Record
System Owner System Location
Kellwood C,),iOry !tub Lean 'ernvuod Country Club Dean
1 ✓-ernwood 't. S. Kernwo(d St,
;alsm, MA. 0,970 ialaer. MA. 01970
x787457[91 +787467284
Cornwood Country Club
Type: Emsrg Routine
Cesspool: No Yes Septic tardy: No ®Yes
Date of Pumping: Ej— — �� Quantity Pumped: CLW Gallons.
System Pumped By: Wind Rin Enwwwwool,, LLC Permit M
Contents transferred to:
Contents Disposed at: C /�
Date: Pumper S"ture:
Condition of System/Other Comments
Dep Approved from - 12/07/95