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Form 4 -- System Pumping Record
Commonwealth of Mossachusetss
: Massachusetts
System Pumoina Record
System Owner System location
.r.I v. rt.
Type: Emergency Routine
Cesspool: No Yes Septic tank: No Yes
Date of Pumping: a/ Quantity Pumped: lSoe) Gallons
System Pumped By: Wind Nver Fnwmnmentoi, LLC Permit 7#:
Contents transferred to:
Contents Disposed at:
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Date: Pumper Signature:
Condition of System/Other Comments
Dep Approved From - 12/07/95
AddressSte°���o�/=c,✓Z.h >T Title of Ffle Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of DocumWe nt/Adion and notes, _
action Document/ document/
Num. Action Department
Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Departrn,ent
107 Fare-stSl. hOFORM 4- SYSTEM'PUN PING RECORD
µiealetcr+ MA 01949
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Massachusetts
System Pumping Record
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Date of Pumping: Quantity Pumped: gallons
Cesspool: No ED"' Yes ❑ Septic Tank: No ❑ Yes LJ
System Pumped by: �-- License 4:
Contents transferred to: ,
Date Inspector