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FORM <br /> <br />the followin~ <br /> <br />c. A ~ield v~$i~ will be required by the Sanitarian to Verify <br /> <br />D~AGR~M OF HOUSE AND <br />LOCAT2ON OF TANK: <br /> <br />W <br /> <br />J <br /> <br />Rev 7/89 pb <br /> <br />SIGNATURE OF PUMPER: <br /> <br /> DATE OF PUMPING:/~ <br /> <br /> <br />