Report -e.i.-vi-.:" ." 4:_ __. PLR
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Department of Health and Human Services r\O(1%/(
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Environmental Health Program
155 N. First Ave, MS 5, Suite 160
:Hillsboro, OR 97124
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'Telephone 503-846-8722 Fax: 603-846-3705 . , Public Health
WWW,co,washington.or.us/hhs/ErwironmentalHealth °REGO
SEPTIC TANK DECOMMISSION (ABANDONMENT)
: Property Owner Name:wease perm 4,,,,,,I.ilit-ri.,/A. ,,,jii-L,,\<,,,4
Township: Range: Section: Tax Lot if:
; Property Address:lnciode city,state,zip) l0 eojjr
e '',,',, <31, DR., 9-2:,1,:)_3
. ::: Was pumped of sludge on:
— 0
I
Date: - 0 tc) „. _ • i
..
...,
I Signature of Licensed Operc4p/AtMoiiiir - . --:‘ c ?' ( : _ License#: .)
dorm....
,
Was backfilled with sand or c can bank run gravel AFTER being pumped of sludge on: .
,
Date: 1
, .
,
'-.., Was connected to city sewer: . 1
V
Date: 6) — 1 —?-011 8 ,^
,/—,-,7--- ;;-'''----/-:---:-------
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Signature of Operator: „ „...40":;;Y//-7 - .,
Oregon Administrative Rules 340-071-01i
5 Decommissioning of Systems 1
The owner must decommission a system when: i
(a) A sewerage system becomes available and the facility the systeni serves has been connected to that sewerage
system; J
(b} The source of sewage has been permanently eliminated;
, 1
(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) 1h 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 I
(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 !
syqem: i
2 Proicedures for Decommissioning:
i
(a) Tanks,cesspools,and seepage pits must be pumped by a licensed sewage disposal service to remove all septage. i
(b) Tanks,cesspools,and seepage pits must be filled with reject sand,bar run gravel,or other material approved by the I
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. i
1
,
Property Owner Signature: ;;//, -:----, Date:
i
08/.