1 Kernwood St. system pumping record 3-15-21 RECEIVED
Commonwealth of Massachusetts
1 City/Town of salem APR 0 6 2021
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�' -_i System Pumping Record
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��; _ ' _� r, CITY OF gALEM
Form 4 BOARD OF HEALTH
\a== 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 Countr . 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
03/15/2021 2500. 0000 _
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes Fj-tl No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
-i- tazr rs—n � g d tcrY Wised w tr t i r-
Covers) 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:
South essex sewerage district: 50 Fort Ave, Po Box 989, Salem MA 01970
03/15/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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