9-30-01 Form 4 -- System Pumping Record
Commonwealth of Massachusetss
Massachusetts
System Pumping Record
System Owner System Location
Doan Karnwrxxi Country Club Kornwood Country Club
1 K"rnwood Avo 1 Kernwood Ave
dalau. MA 01970-165; Salem, KA 01970-1653
19701 74', 72t9 10781 745-1210
Type: Emergency Routine
Cesspool: No Y s Septic tank: Mo^^I�IYes �J
Date of Pumping: 7(7 I Quantity Pumped: SLY6aIlons
System Pumped By: Wind Alter Ear7roamenfal,, LLC Permit
Contents transferred to: j
C i
Contents Disposed at:
Ses y
Date: pumper Signature: a,� �GJ
Condition of s stem/ Comments
Pj mOVJ p
Dep Approved From - 12/07/95
JOT
ut 1 9 2001 V
CITY OF SALEM
HEALTH DEPT.