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al-toI ac\o=IAQ "P <br /> ®py RECIEHME. <br /> JAN 1 2 2026 <br /> ION COUNTY <br /> County BUMADING INSPECTION <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE/PO Box 14500 <br /> Salem OR 97309-5036 <br /> (503)588-5147 <br /> www.buildi ng 5,co.m a rion.onus <br /> HOLDING TANK ANNUAL PUMPING RECORD <br /> Facility Name: /^,5 R V S4-or a. ¢ Permit# <br /> Address:16544 S.tn 11:A* A, Si Date: <br /> Inspection and <br /> No.Gallons Name of Ultimate Disposal Water Usage Alarm Test <br /> Date (confirmed alarm <br /> Pumped Licensed Pumper Site (gal/day) <br /> is working, <br /> yes/no) <br /> • <br /> • <br /> • <br /> • <br /> ----- <br /> • <br /> • <br /> ----- <br /> • <br /> ----- <br /> �----- <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:R BM 04M0 Do Poi &aa *. Phone: <br /> Email Address: IS6VSfua.. , t a .y. .1 .ca r. <br /> Signature' a Date: I -T *L <br />