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NIARION (.:.01INTY PUBLIC'WORKS <br /> '4111r,' IWr.L.DINC INSPECTION DIVISION <br /> • <br /> 5155 Silverron Rd Ni <br /> Salem OR 973()5 <br /> I I .'S.(13si 588-5147 Fax (503)588-7938 <br /> http://wwvi.co.marion.or.w•A`WiBuildinginspection . <br /> NOT!CE ,X1 TTIf OR I Z I NG REPRESENTATI VE <br /> e k_is have authorized <br /> (1)::(Jilertv Owner Print\atri.7.-n, <br /> Herbert C. \Nilsen. r & Lone Pine Corner Septies .r.c. to fiel ,.nv acelit 1 perforrnita:: the <br /> :.Authorrzed ReDresentative Print Name: <br /> neccssar\ to chtain site evaLtations. other ;:vast.e...vau.s.r treatment program <br /> ser 2rovided by the Department o[ EnvJo:mental Quality COILLY AC 7n: on the propctiy <br /> descrFDed ill acconianee with OAR chapter 340. divison(57i. <br /> PROPERTY IDENTIFICATION: <br /> .6.q.J!____11 NO 0.(.411 Lv_ofifer Jok Ins"' <br /> Property Situ or Street Address <br /> )oscrbd Ele reCOrCiS' k1_A ( <br /> egal Description Acres 0. 7,g(frEj'y Nwsly sec;f AY 3 et Ot_ 00 <br /> Subdivision, Lot and i. 775g se ws') <br /> PROPERTY OWNER: <br /> :)rin!ed Narne: ___Kfett ilt\ /..S- <br /> deLev. Date: <br /> Address: 0 3 t. _ _(00c( phone: •563- 77? — 3 Le cit>. slate. Ziaost DA9 73yp Fax: <br /> E-mail Address_ 1__Cs.77._C LipM00 C450-1 <br /> All-HoRizED REPRESENTATIVE: <br /> Printed Name: ,-ierbert C. Wilsor, <br /> Cz..rrnanc-Name: Lone P.'ne Corner Sedtios, <br /> _ <br /> , <br /> 1101..MA.71) p DN-e: / — S- <br /> Addr-;s: 8776 Cascade Hwy. NE. P3one: 5C3 - 873 - 7157 <br /> SLate. Si1vertor„ OR 9738.1 533- 873 - 5562 <br /> _.__... <br /> .Aid7ess. ..igrePipeSeptcs8776 ‘,0!17 <br /> DEQ License 37003 Fc-i-I.33 177063 . _ <br /> ,:sciRNI.S..SITVICS- At T.i'1 IAPPi. 7)i VX t::. 11, <br />