Report • PI, H - 610q - 0(314,/
EXISTING SYSTEM DECOMMISSIONING
The street address for the property is 7Z 75' ✓ i-a1 fr – wid.Sa A/eyy /
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By my signature. I certify that the existing (select one or more of the following)
[ieSeictic tank [ ] Seepage Pit [ ] Cesspool
was decommissioned in accordance with established standards of the Department of
Environmental Quality (DEQ). The DEQ standards require the selected items to be:
A) pumped by a licensed sewage disposal pumping service to remove all septage;
B) filled with reject sand, bar run gravel or other material acceptable to the County. OR
the tank must be removed and properly disposed.
The septage was pumped by � a� f�� Jd�`C—
(Co pang ?)'a e of the septaee pumping business)
Fe) t>C5)C t 2(� (►► , 62. 91609 ,
Si mature • a[ // ��., ('!) 663 - 2 - 8 c7 'Date: Z�� /Z i d
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