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c% Q. Z <br /> a • <br /> :x• MARION COUNTY PUBLIC WORKS <br /> .. BUILDING INSPF.CITONDIYI9ON <br /> _._ 5155 SBvmlon Rd NE/PO'....Box 14500 <br /> Salem OR 97309-5036 <br /> (503)S*5147' <br /> www.eo.maAaorw <br /> East St,6p <br /> t Q.YI k' HOLDING TANK ANNUAL PUMPING RECORD <br /> Facility Name: K &E eXC0.VCti-tf0� Permit <br /> Address: 3gf ._-t I _g _J s�: Date: V t 4 P <br /> Inspection and <br /> Name of Alarm Test <br /> Oak No.Gallons Licensed Ultimate ''., Water Usage (caofmmed <br /> Pumped Pumper Disposal Site (gal/day) alarm is <br /> wonting, <br /> yes/no) <br /> g(l9y� 6 t.000 Ale cultic Fto ljc S <br /> 8 16 . t.2.471 <br /> 913.125 t, oea '.......... <br /> `II%1 Sa 1 .500 . <br /> 9l21}25 1. 069 ''..,.. <br /> toDI3I25 1.oeo <br /> LDjt112b t,3oo <br /> 1sltolz5 1.100 <br /> u12-4125 t.5oo <br /> ttlit?5 4tcoo <br /> 1tttZ19J I.ZAD \,/ V U <br /> This report must be postmarked or received on at before January 31,,2023 to qualify for the reduced <br /> Annual Compliance Determination(ACT))Fee of S70.00. ACD fees for reports received alter January 31 <br /> are 3240.00. <br /> REMARKS: <br /> 1 certify that the holding tank has been operated the previous year in full compliance with the permit,and I <br /> am familiar with the information contained in this report and that to the best of my knowledge such <br /> information is true,complete,and accurate. � " / <br /> Name and Titles ab/ Mi/kr /psnnliblraIilk, Aic/t 4Phon&94l 'Oil ( <br /> Email Addddddrrt�saa Stott,FS ()may (.Gem <br /> Signature:(/, Nn Date: 8' 2 <br />