1 Kernwood Street system pumping record 12-29-20 RECEIVE®
�L\ Commonwealth of Massachusetts JAN 0 7 2021
�,L City/Town of Salem
System Pumping Record CITY OF SALEM
�f BOARD OF HEALTH
- 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 Zip Code
2. System Owner:
Kernwood CountrV 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 12/29/2020 2 Quantity Pumped: 2500.0000
Date Gallons
3. Component: Cesspool(s) X❑ Septic Tank 0 Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes n No If yes,was it cleaned? ❑Yes D No
5. Observed condition of component pumped:
NnrWal ,.
Mdin tine etlecti , Nu zatar le�rel 8"M hottom sludge Sin top solids Both baffles ara intact
oe used with a i-1 ter. Cotner{s) secure .
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
NEMC Yard: 54 Knox Trail, Acton, MA 01720
12/29/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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