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<br /> NIAIZION COUNTY PUBLIC WORKS
<br /> BUILDING INSPECTION DIVISION ' RECEIVED '
<br /> 5155 Silverton Rd NE
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<br /> Salem 97305
<br /> MAR 2 5 2024
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<br /> (503)588-5147 Fax(503)588-7948 . .,
<br /> • http://wvvvrco.marion-or.us/PW/13ttildingInspeetton
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<br /> 1 ! -NOTICE AUTHORIZING REPRESENTATIV,
<br /> I, Lapte • i-Acq rpk, V .. _... .. ., have authorized
<br /> i (Pioperty Owner/Print Name),
<br /> \iikU C3 t•I;)\--1L- to act as my'agent in perforating the
<br /> i (Authorrzed Representative/Prtnt Name)
<br /> activities necessary to obtain site evalttatiOns,,pertnits,and other treatment program
<br /> services provided by the Department of Environmental Quality or County Agent on the property
<br /> described below in accordance with OAR chapter 340,,diViSionO71.
<br /> PROPERTY IDENTIFICATION:.„
<br /> ' - 7 CS—I ---) -ck.:°4_ ''' ,,c.k ),E), C),\A-,C7'::. C3e--- cFAU)
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<br /> Pmperty Situs,or-StreetAcktres$, ..
<br /> Described in the records orMARION County aS: - -
<br /> Legal Description , „ ,,,1 ,,,, , Tak-Lcit
<br /> SubdiVit ion'Lei andBlock
<br /> i - PROPERTY'OWNER: ' --..-, , - ,
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<br /> ' . Printed:Name: LI NI ri f\taA -,R:4719 -410: 71,7_ _ .,
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<br /> sigrpture. , Ni _ _ . Date,tvii4-,
<br /> AddresS:, ,Q10 7,,:'!:-) '0&se 'P,, ._. -ict.,. ,k1—c--- Pbone:_.5-C13-- 3/0
<br /> City,State,Zip , r't51-' , La_K-r'. q IQO a Fax: -,k/./A ..„ .....-,.. „ ..
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<br /> E-rn ail-Additss 4-el. C 0.41'1 • ,
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<br /> AUTItORITED.REPRESENTATIVE: -- ,
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<br /> -e,,c. '6\ Ca. \, QIN, .") • ,. .,
<br /> Printed Name: , - • ,
<br /> ConipanyName: N\te. '•() c.) 1C.
<br /> 1 ' ' 5/` r .(ir,ei ,ievin— -
<br /> , Signature: .,04. , --- -- -,------ ---;---0,-, .., „
<br /> Address:, n 930,1z-- Cl 1-11
<br /> '''• City,State,Zap ?:,l'ci 0{<) )S/,,,. Crib:OS '
<br /> E-mail Address ,-,3,..„mk ce‘ ,.@ at e_btrin,,,,, (,,,,, c:444,r.N.,_,... .,,,,,,.
<br /> $-6015 ' ''
<br /> DEQ Lieense it - „ <J ,
<br /> alFORNOSErnMS-07 AUTHIO 40'LT:1X=fitnkcr I ini CCH ,....9. ri f4
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