1 KERNWOOD STREET SYSTEM PUMPING RECORD 6-17-22 E0EIVED
Commonwealth of Massachusetts JUL 1 5 2022
r City/Town of Salem
m �71 System Pumping Record CITY OF sALEnn
Form 4 BOARD OF HEALTH
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 Country Club
Name
1 Kernwood Street
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787457289
Telephone Number
B. Pumping Record
1. Date of Pumping 06/17/2022 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 � No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
Noripal water gi-n hattow S3-1-'dgQ 4in top Solids Both baffles are intact
Wised with a tiiter. Cover s secure a. No 3rd party paperwork i ed. T is truccT
does not belong out here.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
06/17/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1