Report (47) PLnge)0- 000gcl
Department of Health and Human Services
Environmental Health Program
155 N. First Ave, MS E. Suite 160
Hillsboro, OR 97124
Telephone: 503'848-8722 Fax:503-846-3705 Public Health
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SEPTIC TANK DECOMMISSION (ABANDONMENT)
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Township: Range: Section: Tax Lot#h
Property Address:(include city,stete,
zip) < SkA) t4).�`~4` ~ ~ -r
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\E 'VaspumpedofdudQeon:
|| Date: 312:2-111
Signature of Licensed Operator: AINV.,krielin License |���
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c/Wasbackfilled with sand o,clean bank run gravel AFTER being pumped nfsludge on:
Date: . ��I-~2 tm���
-_ as connected to city
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Signature of Operator:
Oregon Administrative Rule340-071-0185 DecommissioningofSystemmo
1) The owner musdecommission 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 sysem;
(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,
PropertrenmEr
Signatore;-- ^ , . - Date:
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INVOICE
Billed On 03/22/2019
Invoice# 452-403
Unit ft
Due Date 04/01/2019
Check payable to:
American On Site
31881 S HWY 213 Molalla,
OR 97038
Billed To: Job Address: Balance Due
Eric Flefley/Setyv;kc-tel
PO Box 47, 13365 Southwest Watkins $440.00
tvloialla,OR,97038 Avenue.
Tigard,OR,97223
Activity Qty Rate Amount
WASTEWATER TREATMENT/Pumping 1 440.00 440.00
3/22/2019: 97223 Standard- Up to 1000 gallons
Total $440.00
Amount Paid $0.00
Amount Due $440.00
Note;
For payment,please mail a check or call with bank card information.
If paying with bank card,bank service fee will be added.
TermsNet 10 days.
2%finance charge shall be charged monthly on all accounts 30 days past oue.
Should this account be placed in the hands of an attorney for collection,customer will be charged a reasonable amount to cover American On Site's attorney
tees and collection costs even if no suit or action is filed.
Thank you!