10-4-01 : Massactusem
System pumping Record
System Owner System Location
Duan Vrna,ud Country Club Karnwood Country Club
1 Knrnwu:.d Ave. 1 Kernwood Ave.
Lalex.L. MA 01470-1653 Salem 11A 01470--155]
,97A) 745. 72149 19101 745-1410
Type: Emergency Routine
Cesspool: w Septic tank: Yes
Date of Pumping: O/ Quantity Pu Gallons
System Pumped By: Wind River Environmental, LLC Permit#:
Contents transferred to:
OCT ;) 0 9i!
Contents Disposed at: CITY OF SALEM
HEALTH DEPT.
se�.r1�
Date: Q6l Pumper Signature:
Condition of System/ Comments
Dep Approved from - 12/07/95