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�.., MARION ION COUNTY PUBLIC WORKS <br /> -; �=-- BUILDING INSPECTION DIVISION <br /> mom`'_--,••• • 5155 Silverton Rd NE <br /> • <br /> Salem OR 87305 • - <br /> F== (503) 588-5147 FAX(503) 588-7948 <br /> • - • http://pnblicworks.co.marion.orals/building/• <br /> - <br /> • <br /> sRFTIC TANK ABANDONMENT FORM <br /> TTiE S K:NTIC TANK AT: 10 0113 IVo rfi h Fa f k L vt , -5. E, • <br /> - - Lrvt5 0r, • 9.-735g <br /> •• <br /> ACTIVITY NUl�ER - _ — <br /> • WAS PUMPED BY: - Ffwvr.v-.5 S e rt cc <br /> - -DEQ License# 311071 <br /> DA1E TANKPUMPED: 12 23 - Z O <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> '1HE TANK WAS: • <br /> • <br /> REMOVED. •- <br /> [I` FILLED . <br /> (NOTE: The bottom of the tank should be perforated or crackedto prohibit the <br /> accumulation of sutfaoe water in the tank) <br /> Ji1LL MATERIAL: • • - <br /> [] REJECT SAND • <br /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK. • <br /> COMPANYNAME: $q I i eri'�' avvt e 5 LLC , <br /> ' SIGNED: _DATE: 1u /4/f ZO Z 1 <br /> - arc 5-02 " <br /> ler 6(03 - . <br />