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. MARIONCOUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Shales Rd NE i PO Bog 14500 <br /> ._...._._.. Salem OR973®93036 <br /> (503)5113-5147 <br /> wnmataaarbsar s <br /> 1 HOLDING TANK ANNUAL PUMPING RECORD <br /> Facility Name: l4i Leei cAvcttliflj Permit it <br /> &Wets: 1J��'( t.ca1(7eft�"; al Date: 2� ( <br /> O Inspection and <br /> Alms Test <br /> e of <br /> No.Gallons N� Ultimate Wont Usage (confirmed <br /> Dateensed <br /> Pumped Pamper Disposal Site (gal/day) ahrm is <br /> working, <br /> yes/ <br /> 81412,9 244 ALbSetHC Leo Flo S <br /> 91z125 ;lob <br /> 4b1311A 2t2tro <br /> " Z4 2.1 S190 <br /> ketT5M5 ;Sec <br /> 1el'L9ltis 21Se0 <br /> %%Volts 2e, 'eu <br /> a1t41t$ Zpeo 1JI <br /> U426 on 2tle%Vt <br /> Iz�mt{zxi 2t la eo <br /> This report must be poatmmked or received on or before January 31, 2023 to qualify for the reduced <br /> AmW Compliance Determinate(ACD)Fee of 370.00. ACD fees for reports received Ober danumy 11 <br /> are S240.00. <br /> REMARKS: <br /> I certify that the holding tank has been operated the previous year in full compliance with the permit,and I <br /> m toolbar with the information contained in this report and that to the bon of my knowledge such <br /> iotarmatioo is true,canplete,and accurate <br /> Name and Title:S?.nu. FVtttt AtipantbltaIK, tISSts4. t Phone:5111-n4-oBS I <br /> Email Address: A,-to Stet 01.o-lTawl,Cares <br /> Signature:, j1.t - Done: z1ts1 <br />