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1 Kernwood Street system pumping record 10-5-20 Commonwealth of Massachusetts City/Town of s,,: System Pumping Record, Y p 9 Form 4 DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must be substantially the same as that provided here.Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date In accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 1 Kernwood Street Address Salem MA 01970 City/Town State Or,Code 2. System Owner: Kernwood Country Club Name 1 Kernwood Street Address(if different from location)T Salem _ MA 01970 City/Town State Zip Code 9787457289 xclub Telephone Number B. Pumping Record 10/05/2020 1000.0000 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: 0 Cesspool(s) Septic Tank Tight Tank Grease Trap Other(describe): 4. Effluent Tee Filter present?, Yes© No If yes, was it cleaned? Yes No 5. Observed condition of component pumped: r ]_y-- - 1 cl Fin bott-om. cl rlr Fin to 901 i As Tnl t baffles are intact r t6 15 use wi a f i ter. over-�s'� S2CllreQ._ eC�'] -l�SG IRflln-IClaln 1riA t0 tank 1S broken and that's why it's clogged. 6. System Pumped By: Robert Hall Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: 163 Western Ave, Gloucester, MA 01930 10/05/2020 Signature of Hauler i Date Signature of Receiving Facility(or attach facility receipt) Date t5form4,doc•11112 System Pumping Record•Page 1 of 1