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FORM 4 - SYSTEM PUNLPLhG RFCG _
Commonwealth of Massachusetts
Massachusetts
System PumQing Record
J stem 77mer ystem LQcaa�n-----
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pe Emergency �7— Routine i=/
essooci. 'o Yes L1 Se tic '?-an:;: No ❑ Yes
D e[ PL.-,, Quantity Pumped
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Contents transierree to:
Con!ens disposed at:
o
SEP 13 2006
CITY OF SALEM
rsr Fc TJ : l`, y BOARD OF HEALTH
FORM 4- SYSTEM PUMPING RECORD
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�1 N'T 2 5 1949 Commonwealth of Massachusetts
CiTYOFSALEM , Massachusetts
HEALTH DEPT.
System Pumping Record
ystem wrier System Location
6�a/� 0A
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Type: Emergency ❑ Routine 93e,�-
Cesspool: No ❑ Y El Septic Tank: No El Yes
Date of Pumping: O67 Quantity Pumped: 7,50 gallons
System Pumped by (Company): led Permit 9:
Contents transferred to:
.Contents disposed at:
Date 17lulmn Pr Q; atilre
Condition of system/other comments:
DEP APPROVED FORM-12/07/95
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