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1 Kernwood Street system pumping record 6-21-21 RECEIVED AUG 0 2 2021 Commonwealth of Massachusetts la} City/Town of Salem CITY OF SALEM BOARD OF HEALTH i� System Pumping Record 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 0197C City/Town State Zip 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 06/21/2021 2. Quantity Pumped: 2500.0000 Date Gallons 3. Component: ❑Cesspool(s) ICJ 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: Normal- wat:Qr I-ovQ1- 21iz� bottom slAidge 5;Ln top solids Both haffles ara intart e used witt a tilter. Covers . secured. No . rd party paperwork it ed. 6. System Pumped By: Michael Graham Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste 4110, Hudson, MA 01749 Company 7. Location where contents were disposed: I South essex sewerage district: 50 Fort Ave, Po Box 989, Salem , MA 01970 06/21/2021 REC> Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date 1 TOWN OF AUSU ,i1t t5form4.doc•11/12 System Pumping RecoWkSge 1 of 1