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ll-boka91-IN 4'? <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> uni_`_= 5155 Silverton Rd NE I PO Box 14500 <br /> Salem 97309-5036 <br /> (503)3) 588-5147-5147 <br /> www.co.marion.or.us <br /> HOJ,y/DING TANK <br /> �� ANNUAL PUMPING RECORD <br /> Facility Name: 1TJ//7LI/ AIt c¢ G'c a d— Permit# /0,265- 2 <br /> Address: /:/a S K f(0IA iat� Date: S:tp 2� 202,C, <br /> v� 1 JYL. //*zk1OI. ,C7 9 i <br /> S ✓ Gc( I Inspection and <br /> Name of Alarm Test <br /> No.Gallons Ultimate Water Usage (confirmed <br /> Date Pumped Licensed Disposal Site p PumperP (gal/clay) alarm is <br /> working, <br /> ,3� roc/ 3, 5-6 �e nn) <br /> /� `� y <br /> �j 5 E <br /> This report must be postmarked or received on or before January 151°of each year to qualify for the <br /> reduced Annual Compliance Determination(ACD)Fee of$3 0. ACD fees for reports received after Jan <br /> 1511 are$240.00. aft> 7sdt" <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,comJpJJ te,and accurate. <br /> Name and Tille: (/-' (,(/ ac MA Kf_42< Telephone# 5r-2,3 -9)y 7:24Signature: ai' Date: ///i/iZ <br /> O:\Onsite SEPTIC\Holding annual reportdoc <br />