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�: tYrart Vl`( �.VUlf1S. .CU.Dij.LL Y`'UJ <br /> B' TN@3NSPECTION DON • <br /> • .. • <br /> 5155 i er NE <br /> • Salem OR 9-7305 • <br /> r =t (503) 5888-5147 FAX(503) 588-7948 <br /> • - http://pnblicworks.co.z rion.or.us/buildfng/ • <br /> • <br /> • <br /> • <br /> 8F,PT1C TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: I 3 333 14 RA , , <br /> sduefto,k r, CI7 3 <br /> ACTIVITY NUMBER: 5S S —3: 1�O Lf3 — PR M — —__ <br /> • WAS PUMPED BY: 0 rc5 ay\ P vt )15 <br /> .DEQ License# <br /> DATE TANKPUMPED: ' <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT Willi THIS FORM. <br /> TPTE TANK WAS.: . <br /> REMOVED 0 - <br /> []` FILLED ' <br /> (NOTE: The bottom of the tank should be peiforated.or cracked-to prohibit the <br /> accumulation of surface water in the tank) • • <br /> PILL MATERIAL: • _ • <br /> [] REJECT SAND <br /> [] BAR RUN GRAVEL <br /> [] CRUSBED ROCK • <br /> . <br /> -COMPANYNAMB: S4 l! - 0, .n s L® , - <br /> • ,SIG—ND: • �-n-' :D A1'E: cp , / . <br /> • MC S-02 • - <br /> rer.6/03 .• • . <br /> • <br />