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MARION.COUNTYPUBLICWORKS <br /> ,RumpIN,GA*PE.e.TioN onriswr <br /> 5155 Silverton Rd NE, <br /> IMO ' Salem OR 97305 <br /> (504)58&5147 FAX.004 5884948 <br /> ' - littptiiptiblitiOrkS:d0.Mation.ntatsibitildine <br /> SEPTIC TANK ABANDONMENT FORM <br /> piE$Enic TANcAT: f 7 2:ct;S'-'. :(....>e_,_V. L <br /> Acl'IVITY NUMBER:: SSS - 3 <br /> WAS PUMPED BY: Aw'exi:C..c..4,v8,_ 1ZS.,642*.C.C- . <br /> DEQ License# Sq4 , <br /> DATE TANK PUMPED:: <br /> ENCLOSE A COP1)-.OF tilt kvivinsiOiocwrir wow TO:is:FORM. <br /> THE TANK WAS: <br /> 'REMOVED <br /> TILL, ED . <br /> (NOTE:The bottom of the tank should be perforated or cracked ta prohibit the <br /> 'aectmudation of surfaceuiaterin the.tank) <br /> FILL MATERIAL'. ': <br /> [] BAR RUN GRAVEL <br /> CRUSHED ROCK <br /> Affordable Septic Systeins, <br /> . <br /> 32948.:Brewster:Road <br /> LebotfoO!OR 97355 <br /> COMPANY NAME: <br /> , <br /> SIGNED: ' - DATE: 7-177 arcl <br /> mc s-oz, <br /> rev:610,12110, <br />