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CERTIFICATION OF TANK DECOMMISSIONING '>Li. N (99 1
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Parcel number 70 ( 17 { O e4, 0,6-
Address "to < < \ ddi,
Property Owner Na e6--a4
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Septic Permit# (if applicable) .- OS. act 2-
Individual/Company Certifying Abandonment
715-0i) NIa - (DWI._ 1-1-C-
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Phone Number 3(¢0 Lib 1 — 4 g&
I certify that all sewage was removed from the septic tank and/or pump chamber
on the above referenced site by a Jeffer n County Certified Septic Tank
Pumper, the tank filled with soil or gravel.
7-11E `- (z�erg Dr5,C540 (�l` J-(M-wizLL I/4e-- .
I certi thht e septic tank and/or pump chamber on the above referencedyste ( _
has been decommissioned to Washington State and Jefferson County Public Stt.”
Health Requirements.
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Si ure - / A Date � b
Pr t Na - I . N " c_i,
Pump receipt attached
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H:\WEB\EH-WQ\SEPTIC\Appl ications-Forms\cert_tank_abandon.doe
1 JONATHAN SHOTWELL CORP
Top Soil P.O. Box 2081
Pea Gravel Port Angeles,WA 98362
Septic Services Drain Rock (360)457-1417
P.O.Box 208 Binder Soil Fax: (360)457-1416
Port Angeles,WA 98362 Accept Rubble Cell: (360)808-2461
Baseball Infield Mix
(360)4374596*(360)385-2557* (800)9744557 Horse Arena Sand Cell: (360)670-1378
"YOU'RE#1 IN OUR#2 BUSINESS!" S 711 4.,8
NAME , 3
f TOM R •�='�a R PHON DLito ADDRESS
/42
NAME ` I PHONE
���,,,T r kk C r, .3 77-ie r a
SOLD BY CASH C.O.D. CHARGE ON ACCT.
ADDRESS
1 DRVR.
CITY,STATE,ZIP `. QTY. TIME INT. DESCRIPTION
COI lay I CASH I C.O.D. I CH r_G I N A QCT I g
D f... �OvAR..� �..,-.�.: MDQ I Dpin(y41T
RETD ,..rq ,
QUAN. DESCRIPTION PRICE AMOUNT
1 A" ' Rk. '1 n 1 ,./ tr/../c ) t...C.; CI (1 i 7c-t, . ....,.,
2 '-J :
3 o e- f
4
5 ,,,c g, E.) 6 g - o ea 9a , ,
, fir
6 , ,S a p *7 to - S3 1
7
8 , 774 PR.5 pckr4
9 <L ch an
101
TAX ti ��
i1 16
RECEIVED BY
TOTAL 7
RECEIVED BY 13 7 �,
TANK LOCATION/SIZE:
e?. 0 f--&,,g., 1 87 C) ,
tP
PLEASE PAY FROM THIS INVOICE
TERMS ON REVERSE
- -
JONATHAN SHOTWELL CORPORATION
- Top Soil P.O. Box 2081 Overburden
Pea Gravel Port Angeles,WA 98362 Dirty Ballast
•„' Drain Rock (360)457-1417 Clean Ballast
Binder Soil Cover Sand
Fax: (360)457-1416
Accept Rubble Reject
Baseball Infield Mix Cell: (360)808-2461 Crushed
Horse Arena Sand Cell: (360)670-1378 Crushed Concrete
NAME
ADDRESS
PHONE DATE
SOLD BY CASH C 0.D. CHARGE ON ACCT. MDSE.RETD.
QTY. TIME DRVR. DESCRIPTION PRICE AMOUNT
INT.
F
a
I
".417('S 6 A.P .'4'1<114ieir
tt.t,
*et
, •
TAX
RECEIVED BY
TOTAL
•1 7 5