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. <br /> IAItIt1NU1LDL COUNTY I'i11ILTIONXG1VIS'W+QRI£5 :, <br /> . �.`�� 111�it�Ii`�C UT ', � , <br /> � , . 5155•SSilvertan Rd St <br /> Salem OR 97305 <br /> (503)55 -5147 F'A (503)S$11-79 8 <br /> rusllra iI• <br /> . <br /> e nn ano , <br /> uBi' or . o. , <br /> - <br /> , 1i icty ka <br /> : <br /> ' ' ". '.-SEPTIC TANK ABANDONMENT•FORM _ , .. , <br /> 'THE SEPTIC TANK AT: I S .,Sli+.^� <br /> c - .` <br /> , <br /> ACTIVITY NUMBER: ., <br /> WASPUVWEDBY •. ff) <br /> DEQ:License#. l .& ' ' <br /> :DATE TANK PUMPED: 7 <br /> ll <br /> • ENCLOSE A'COPY.ORtfi x,PUMPI NG RECEIPT NINTH THIS FORM. <br /> THE TANK ?VAS <br /> REMOVED <br /> i <br /> FILLED •� g r r <br /> . '(NOTE The bottom•of thejtank should be perforated or cracked to prohibit the , ` <br /> accumulation of surface water m the•tank) <br /> F FILL IvIATERTAL • • , <br /> a (), �RE.XEC.T SAND <br /> L]- ARRUN'GRA <br /> [-1 CRUSHED ROCx } <br /> `�OMPANXNAME <br /> SIC"iN.ED. • DATE: f <br /> rcv:�1�►3,ltito <br /> r :. <br /> ;` € j ' a „.. rn . - gy m,. <br />