Correspondence / r
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Lii' Stinky 4 ENVOJOIB
Environmental Service -
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COMPLETE SEPTIC SERVICE yam'
19631 S. Kolar Dr. �r - a �" :" S ATE / ^ /`�
Oregon City, OR 97045 .5- / 9 ` LJ
sow, NUMBER
Molalla:(503) 829 -8458 m Oregon City: (503) 658-0518
Fax: (503) 722 -7186
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PLEASE DETACH AND RETURN WITH YOUR REMITTANCE
BALANCE FORWARD
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PAY LAST AMOUNT
yy IN THIS COLUMN
SIGNATURE A _ f ,_
Terms The 10th of thG month following purchase. 2% finance charge on all past due accounts 24%
annual In the event this invoice is not paid as agreed and the account is placed in the hands of /' ^
attorney for collection, then Lil' Stinky Environmental Service shall be entitled to recover its Th ' YO
reasonable attorney fees, in addition to court costs, in any legal action commenced to collect debt P !- a ZeO� l:
MAY -06 -2010 THU 01:54 AM WASH CO HHS FAX NO. 5038464490 P. 01
r oar SEPTIC TANK DECOMMISSION (ARANDONNIENT)
'` For Onsite Sewage Disposal System
' - ` " ! _ ` Washington County Department of Health & Human Services
Environmental Health
• .ro 155 North First Avenue, MS 5, Suite 160 • Hillsboro, Oregon 97124-3072
Telephone: (503) 846 -8722
Please return completed form to Washington County Department of Health & Human Services •
Environmental Health
) 14 2 —sk" Is P olcooVoo
Township Range
Section Tax Lot # (s)
2_ 4 Th / 41-6
Printed Name of Property Owner
3. The septic tank located at 1 / £ 4 r ° qs
1 .. ti l k / ` � Slate � �" � p e
Address City
flj Was pumped of sludge on: 3
Date: (r7 -/D
By Uoensed Operator. • L L i c ense #: `' a� 3 '
c► Was backfilled with sand or clean bank run gravel AFTER being pumped of sludge on:
Date: -C` t 7 - J6 Signature of Operator
Oregon Pilmtntstrative Ri1lcs 340 -r1 1S5 De orr miSs;ornctg of Systems
1) The owner shall decommission a system when:
a) A sewerage system becomes available and the building sewer has been connected
thereto; or
b) The source of sewage has been permanently eliminated:
2) Procedures for Decommissioning:
a) The tank(s), cesspool or seepage pit shall be pumped by a licensed sewage disposal
service to remove all seepage;
b) The tank(s), cesspool or seepage pit shall be filled with reject sand, bar run gravel or
other material approved by the Agent, or the container shall be removed and properly
disposed.
The septic tank at the address above has been decommissioned in accordance with Oregon Administrative
Rules.
Signature of Property Own er: AP
WCOHHS EH Revised April 2007