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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE/PO Box 14500 <br /> Marion Salem OR 97309-5036 <br /> County (503)588-5147 <br /> www.buildinv(&,co.marion.or.us <br /> HOLDINGO TANK ANNUAL PUMPING RECORD <br /> Facility Name: SJaLkf.c1 Vov I.pDR4 Permit# & <br /> Address: I(Dq l m Pot-I-Lao fleAD vie- ISQ1-S Date: D m 5 aic <br /> oe- 30S <br /> Inspection and <br /> Name of Alarm Test <br /> Date No. Gallons Licensed Ultimate Water Usage (confirmed <br /> Pumped Disposal Site (gal/day) alarm is <br /> Pumper working, <br /> yes/no) <br /> Via las 3(sc1 cariA tali, LOOOD(31)e-n <br /> wn� IfPcarlc (\ <br /> tin 115 3l0()!0 <br /> dlaul2c 5,�IO& <br /> gin-f((a mB 5 3m <br /> O&j t )a6 ll-CD <br /> 5) 1A )as J 3toOO <br /> (o 4195 53OO <br /> 7 14 1c ,3r3oo <br /> 8' tala5 3oo0 <br /> g'Is/ 5 a W aCtLP Atnc <br /> This report must be postmarked or received on or before January 15, 2026 to qualify for the reduced <br /> Annual Compliance Determination(ACD)Fee of$82.00. ACD fees for reports received after January 15, <br /> 2026 are$240.00. <br /> REMARKS: <br /> I certify that the holding tank has been operated the previous year in full compliance with the permit, and I <br /> 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 Title: J te- 4/ P Phone: soj -10)3-3-1 J°1 <br /> Email Addre /YI <br /> Signature: Date: alD <br />