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1 KERNWOOD STREET SYSTEM PUMPING RECORD 10-15-21 RECEIVED Commonwealth of Massachusetts DEC 0 9 2021 City/Town of salem CITY OF SALEM 1a System Pumping Record 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 WA e 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 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 10/15/2021 2. Quantity Pumped. 2500.o000 Date Gallons 3. Component: ❑Cesspool(s) )c 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: Main tine Ctedr. Nu fittei is pie6eiit un tile tailki CLILLellt rank ts flut destylled to e used witn a filter. Covers secured. No arc party paperwork filled, 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: 163 Western Ave, Gloucester, MA 01930 10/15/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1