1 Kernwood Street system pumping record 10-21-20 Commonwealth of Massachusetts
City/Town Of Salem RECEIVED
b System Pumping Record
Form 4 DEC 012020
• 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 He4th-ftZYd&—ltFrr8)&jLE Form
they use.The System Pumping Record must be submitted to the local Board of Health or other appr8 A$0 r *fffA TH
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 Zi. Code
2. System Owner:
Kernwood Country Club _
Name
1 Kernwood Street
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787457289 xclub
Telephone Number
B. Pumping Record
1. Date of Pumping 10/21/2020 2. Quantity Pumped: 2500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
Normal water laval 10i-n ]Dottom siudgQ lin top solids Bath baffl-P-2 are intar-t
�d--with a filter. over s secured.
6. System Pumped By:
Robert Herrick
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
10/21/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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