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d0[ '-A )❑ ItL>y% - t <br /> IS 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.building(7a,co.marion.o r.us <br /> a9 w as i,Q9? <br /> HOLDING TANK ANNUAL PUMPING RECORD <br /> Facility Name: Brown's Island Permit# <br /> Address: 2895 Faragate St. S. Salem, OR 97302 Date: 2/25/2026 <br /> Inspection <br /> and Alarm <br /> Name of <br /> st <br /> Date No.Gallons Licensed Ultimate Disposal Site Water Usage (confirmed <br /> Pumped l Pumper (ga day) alarm is <br /> working, <br /> yes/no) <br /> 3/18/25 2000 Ace CityOfSalem(COS) Y <br /> 8/1/25 1800 Ace _COS Y <br /> 11/25/25 1600 Ace COS Y <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 /> infonnation is true,complete,and accurate. <br /> Name and Title: Andrew Johnson Phone: 503-566-4184 <br /> Email Address: ajohnson@co.marion.or.us <br /> Signature: /jS�Date: r9, <br />