8-1-01 Form 4 -- System Pumping Record
CommomveaMh of Massachusetss
: Massachusetts _
System Pumnina Record
System owner System location
Kernwood Country Club Kernwood Country Club
1 Kernwood-94 AUE. 1 Kernwood.,
Piet AuE.
Salem, MA 01970-1653 Salem. MA 01970
(978) 745-1210 (978) 745-1210
bea N cF7g 7 ys , 7 zgg?
Type: Emergency Routine (�
Cesspool: Flo Yes Septic took: hlo pC Yes
Date of Pumping: Quantity Pumped: Gallons
P mpsf�F�or�/6=-�
System Pumped By: Wind Riney Environmental, LLC Permit
Contents transferred to:
Contents Disposed at:
Scie
Date: A Pumper Sigcature: -
Condition of iyothw Canunents
Dep Approved From - 12107195