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Mi) attu-5:147 PAX(503)588-7948 <br /> littp://publicworks.co.mation.or.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: <br /> — o/5, E7r 7- -3.52 ' <br /> ACTIVITY NUMBER: 5.:5-',2..I QO:to tf a 'P/zAfT cal <br /> WAS PUMPED BY: .y <br /> DEQ License# 3 <br /> DATE TANK PUMPED: 4 m,2!` <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> REMOVED <br /> [] FILLED <br /> (NOTE: The bottom of the tank should beperforated or cracked to prohibit the <br /> accumulation of surface water in the tank) <br /> FILL MATERIAL: <br /> [] REJECT SAND <br /> [ ] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME:,/9 f co . rveces j <br /> SICrNEDr"j'� v'� � DATE: 7ZrD2.1 <br /> MC S-02 <br /> rev:6/03,12/10 <br />