1 KERNWOOD STREET SYSTEM PUMPING RECORD 8-25-22 Commonwealth of Massachusetts
RECEIVE®
+mi City/Town of Salem SEP 2 9 2022
System Pumping Record
Form 4 CITY OF SALEM
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DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information musETe
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
Telephone Number
B. Pumping Record
1. Date of Pumping 08/25/2022 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 FjV-] No If yes, was it cleaned? ❑Yes 11No
5. Observed condition of component pumped:
Normal water le"'al 36in bottom s]QdgQ 36ii4 tGp sGlids Main line Clear- No filtkr
Cover s secured. No 3rd party paperwork filled. Attempted to pump. Too solidified.
Tried with power wash, no solids able to break down.
6. System Pumped By:
Jay Beaudoin
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
08/25/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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