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Report P1,141?C' — 003O8 G-tox,co DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL HEALTH PROGRAM 155 North First Avenue,MS 5.Suite 160 Hillsboro,OR 97124 Telephone:(503)846-8722•Fax:(503)846-3705 °REG& 2 L__;.11.2__ :1` :1 SEPTIC TANK DECOMMISSION (ABANDONMENT) c.—cpi4LN pl. 4AJ/ 4' ir( fiAl Property Owner Name: (please print) - L2 I If-d. TY,Spe,44," 5-103,14-tl(c.:, Township: 1 6 .1/0 0 Range: Section: Tax Lot#: ;; r • Property Address: (include city,state,zip) )1100 Sto4 wAvyyr si-Reor 1(4A CGeti l';•4 Was pumped of sludge on: Date: Signature of Licensed Operator: gueeiv 4011,Ait. License#: 4ARD1494 Was backfilled with sand or clean bank run gravel AFTER being pumped of sludge on: Date: 11//51219/b Signature of Operator: AvsnAt Oregon Administrative Rules 340-071-0185 Decommissioning of Systems 1) 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 sstern: (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 septagc. (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 -0 ,‘ Property Owner Signature: /•-r. t ( Date: i` f4. 12/1.