5-1-01 Form 4 -- �umRcemd �
Commonweakh of Mazsochusatss
Massachusetts
System Pumping Record MAY 2 1 2001
CITY OF SALEM
HEALTH DEPT,
System Owner System Location
Kernwood Country Club Kernwood Country Club
1 Kernwood Street 1 Kernwood Street
Salem. MA 01970 pp���j,�r nO o /� Salem. MA 01970
(978) 745-1210 IN6, �/'G7l Pegg (970) 745-1210
Type: Emergency Routine
Cesspool: No Yes Septic tank: w Yes
Date of Pumping: Quantity Pumped: p?�Ilons
System Pumped By: Wind River Environmental, LLC Permit#:
Contents transferred to: .
Contents Disposed at: cc c
J� J�
Date: pumper Signature: e P.
Condition of System/Other Comments
Dep Appnved From - 12/07/95