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System Owner ._ yste:rra >r,oc€aticarr-mm._..___._._.________._�._.__.__....._.__.
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Date of Pumping: /,,��W� � ��..._�".. ����,�.��.�.� Quairtity Pumped: gallons
Cesspool: No "�'egn � � Septic r ry N t (_._� "des
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System Pumped by: gaeemaee License#
Corrtents trraarsl�rrreal to : Greater 1wrencesal
Date: --- ---- ------ - _ Iarspector.
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FORM Q - SYSTEM PLAfPING RECORD
Commonwealth of Massachusetts
Massachusetts
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System l e r
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Date of Pumping: -
p g; ' Quantity Pumped: gallans
Cesspool: No - Yes ❑ Septic Tank: No El Yes 11
System Pumped bN•: � � License #:
Contents transferred to: 61) -. µ
Date Inspector