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01/09/2019 21:27 5038297676 AMERICAN ON SITE PAGE 03/15 <br /> ,.,, MARION COUNTY. 'A <br /> .���ANi '";s" ` BUILDING INSPECTION DIVISION ' RECE, VE a5 Silve on Rd NE-_ i'__`-x"1 1 X7 5 <br /> _yr�.��� seem Q 9s JAN o g 2019 <br /> . OM (503)588-5147 Fax(503)588.7948 <br /> http://www.co.marion.orms/PW/Buildinginspection MARION COUNTY <br /> - BUILDING INSPECT-ION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> a ,have authorized <br /> • er!Fria none) <br /> to act as my agent in performingfile <br /> to �,f.'.L. r!Z �I e I FrLitName) <br /> (Authoorised Representative t <br /> activities necessary to obtain site evaluations,permits,and other onsite wastewater ireatme t the pro <br /> gram <br /> services provided by the Department of Environmental Quality or County 8 <br /> ett rty <br /> described below in accordance with OA1.ahaptor 340,division OIL <br /> Property Sites or Street Address <br /> And described in the records of MM2N.Cotetty as; Tax Lot#(s) <br /> Legal Desaz on 3 1 <br /> oPTY O <br /> • <br /> printedIName: I-. e`er= <br /> Signfifif <br /> store• .. <br /> • j^e Date: to-5 . <br /> • • �� Phone: a3-8y <br /> - D r_ Pax: <br /> City,State,7. p °- I . <br /> PrwtedName• '� <br /> �e AM .., ,. „ .. <br /> ,�. <br /> Company Name: mi .,...i, r .. il ` ' ~mi <br /> Signature I�..-� • � *iia Dare: 17 <br /> Address: 31 IS'1 • 1,1 A! _. phone: 503~8'751-76OD0 <br /> City,State,zip /I 0 A ' /Q _ r' _0,, i sec: S2' -P7(07(4 <br /> Address..Ct 5-6. al tin,..e FW )....... ..... ....... ... .. ................„ ,_ �� -. ---,.: .DEQ License# .d `-1 L” ,CCM# 15 -LI <br /> aWORMEASEPTIea.s,Ath.to, 1y ,. <br /> MCS-O7 Rev 0311D 4 <br /> BEPTIC , <br />