1-29-01 Form 4 -- System Pumping Record
Commonwealth of Massuchuseiss
: Massochuse"s
System Pumoina Record
System Owner System Location
Kornwood Country Club DC'Cl JI/ Kernw6od Country Club
l Kornwona Str, , t 1 Kernaood Street
SaL MA 01970 Saler MA 01970
VZ745-1210 fi",� t97a) 745-1210
Type: Emergen1;0:(�
vvRoutine
Cesspool: w Yes Septic tank: w =Yes Q
Date of Pumping: I I Quantity Pumped: &M 6allons
System Pumped By: Wind River Environmental, CLC permit 7i:
Contents transferred to:
Contents Disposed at:
Se,SD
Date: a q Q Pumper Signature: --.ge, C , .
Condition of System/Other Comments
FEB 5 2001
Dep Approved from - 12/07/95
CITY Oft SALEM
HEALTH pEpT,