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N ,B <br /> D <br /> m <br /> �� <br /> �OCOP PU , W;. • aAa ,�aaUii�� Il DH4C SPECTIO 0Q <br /> Fp <br /> - - ' 5155Sity on d;NE. --,- = -,,. � Salem OR 97305 '.UL13 2023= » ( 3)588 5147 Fax(5031587948 •.http //ii w*co.inarion:ear,tis/PWlfluildingInspection MARION COUNTY <br /> ` <br /> BUILDING INSPECTION <br /> - NOTICE AUTHORIZING REPRESE TAT , .. <br /> I K C�`-. f3- ' fl ..have authorized <br /> . , , : ,. <br /> ( r Owner I Print Named _ <br /> �- t.. ,5� •to act.AS.illy agent in;performing tl"ie <br /> (Authorized R.epresentatiwe I Print ame <br /> u <br /> ac+ vibes necessary to obtain site evaluations,p� ,and other,onsite waste ter treatment program <br /> ' ices-pro ided by the otEn rm tal Quality or,County Agent on'me property: <br /> descn'hod r'beloCv in accordance with:OAR:chapter 40,division 07I. <br /> PROPERTY IDENT CA'I IO . <br /> ;Property itus car Street Address <br /> And describeditt the;necords of MARION County as ` <br /> Legal Description -. , , TaxLotn(s) CD . -_" to . <br /> ' PROPERTY t)t7 :" . <br /> Printed Name:. t611-‘ , <br /> I S atur`e .�f.. ^ -- ;1, ,/' T' t Date /" <br /> !: Address: 5 -t 1G u YI + Phone. 70: . L,,`7 2,GO, <br /> 1 City,;State,Zip.' ' k O L. c1' -I. '' Fax . <br /> E-mail Address' K6u ,� A el t' r i v ter- .'L ' <br /> AUTHORIZED REPRESENTATIVE;; <br /> ' ?nnte!4I Name: `, s • 1 ('..;, " <br /> Catnpany � / 3 <br /> 1 <br /> Signature, -Z Date '''.[.,i, ,',/,t .. <br /> k <br /> .Acictress:.. - t�X` . t-� ° . Plwire: - 1 , z c}s t <br /> City;State,Zip, t+C' 1 AL t '-th 7 Fax <br /> E:=i ll Address , 6),e . , . , " ^t' <br /> .UEQ License# 3 ( CCR#f t' 5 g. <br /> £s-07 Rev Plo <br /> fie 4 <br />