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FORM 4 . SYSTEM PUMP NG RECORD
Commonwealth of Massachus�ttsF
Massachusetts -
Sstem . 'um in .pec rd ,
ystem ovation
�y-StU weer
K4 D-e
T7 06' �� 1qq
Tvpe Emergency
Routine
11
❑
Cessp( DI: No
Yes ❑ Septic Tarnl:: No ❑ Yes
Date c Pumpine:
)hl9 '�� Qua lcv Pumped: r _ gallons
BORACZEK'S Permit
S\ stei Pumped by (Company):
Cort: is transferred to:
C,�nt. )Ls disposed at:
Pum er Sienarureti�
Con, tion of systemiot_her comments:
' .1
y
DEE ,.?PROVED F'OR.NI 1:101/91