Report I i°REG& elepnone:(3U3)846-8722 a lax:(503)846-3705
..ww.eo.wash ngtottor.u::'hhs'environmei taihealth
SEPTIC TANK DECOMMISSION (ABANDONMENT)
Property Owner Name:(please print) . 1L1EJJ j.`k &E-9' LC/pi 1i(,- /'T•
Township: Range: Section: Tax Lot#:
Property Address:(include city,state,zip) (.A..) gA)
Was pumped of sludge on:
Date: A Q A.A.L 21 ' ,9'/-9 •''
Signature of Licensed Operator:
AP G�� 4IF License#: 110(461-3
Was backfilled with sand or clean bank run gravel AFTER being pumped of sludge on:
Date: ikpc4L 22!" 76//,5
Signature of Operator: _ r
Oregon Administrative Rules 340-071-d 85 Decommissioning of Systems
I) The owner must decommission a system when:
(a) A sewerage system becomes available and the facility the system serves has been connected to that sewerage system;
(b) The source of sewage has been permanently eliminated;
(c) The system has been operated in violation of OAR 340-071-0130(13)and a repair permit and Certificate of
Satisfactory Completion have not subsequently been issued for the system;
(d) The system has been constructed,installed,altered,or repaired without a permit required in this division,and a permit
has not subsequently been issued for the system;or
(e) The system has been operated or used without a required Certificate of Satisfactory Completion or Authorization
Notice and a Certificate of Satisfactory Completion or Authorization Notice has not subsequently been issued for the
system.
2) Procedures for Decommissioning:
(a) Tanks,cesspools,and seepage pits must be pumped by a licensed sewage disposal service to remove all septage.
(b) Tanks,cesspools,and seepage pits must be filled with reject sand,bar run gravel,or other material approved by the
agent,or the container must be removed and properly disposed.
The septic tank at the address above has been decommissioned in accordance with the Oregon Administrative Rules.
Nir
Property Owner Signature: ., v-J -- Date: 4//2c) "1)//d,61
pn, `' 5 OO(5--0 12/11