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—b[X1423C9TS <br /> rx MARION COUNTY PUBLIC WORKS <br /> ' BUILDING INSPECTION DIVISION <br /> ._ rertnn Rd NEl PO Box 14500 <br /> .. _.._....._. 5155 SBSalem OR 97300.5036 <br /> (503)580d147 <br /> rower a.marlooar n <br /> EA St 5‘^314P <br /> .tic. HOLDING TANK ANNUAL PUMPING RECORD <br /> Facility Name: K &E 6cc v4-f-i n3 Permit# <br /> Address: 3fl! Long(& sk. Date: 2(Ig+2{o <br /> Impeetimand <br /> Alarm Tat <br /> Name DateNo.Gallons Li <br /> Date Water Usage (confirmed <br /> Pumped Pumper Disposal Site (gal/day) alum is <br /> workin& <br /> u aSa Cs-)♦ l tern <br /> Erni z $50 111.11.111111111.1.1.�� <br /> B 1F = 2-1400 MIN 1.11.11111 =MEM <br /> tricall 2 000 ���� �� <br /> 1.11.111111111a <br /> �1�11F� t h 0 _111111111� MOM <br /> =HMI top —�_—sea MI _��.. <br /> Q®� 2.Soo 1111111111111•1 <br /> ELM t oeo 1111111111111111111111���� <br /> =MI t eon 1111111111111111IN���� <br /> c too a������ <br /> Olint San��a <br /> 1.to• <br /> This report aunt be postmarked or maeived on or before January 31, 2023 to qualify for the reduced <br /> Annul Compliance Determination(ACD)Fee of$70 00. ACD fees for reports received after January 31 <br /> are 3240.00. <br /> REMARKS: <br /> t eatify that the holding tank has been operated the previous year in MI compliance with the permit,and 1 <br /> am familia with the information contained in this report all that to the best of my knowledge such <br /> informuiom is tone,complete,and accurate. AA 1� �e,,f�'� <br /> Name and Title:�ggaye 4 ti.' t4aJhS,'k't.' .- Phone:5j4l',an-� <br /> Email Address: a+h A. [nM <br /> Si '' - Date: zllslzo <br />