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PULAic Health
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CERTIFICATION OF TANK DECOMMISSIONING 04:44/? O
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Parcel number `7 p I — 1 74 - 61)(D 6 c
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Address ct I. to p *(L- Imo` . \ tit`
Property Owner Name 't' NV-1 ptT U- S C Vr(2-j .
Septic Permit# (if applicable) E-P [ -- 4 �2-
Individual/Company Certifying Aband nment
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Phone Number ` t0C, 4(0) Y: �s-
I certify that all sewage was removed from the septic tank and/or pump chamber
on the above referenced site by a J� ersln County Certified Septic Tank
Pumper, the tank filled with soil or gravel.
TNS. c1-- pomp cc-IA-AAA-1x U.s 0r46-0c D •� icsp�'�/�
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rtify that the septic tank and/o pump chamber on the above referenced site g�
has been decommissioned to Washington State and Jefferson County Public g/icscr
Health Requirements.
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Sig•ature i Date ( f '
Pri,t Na • 0 / . ►& Ii1 S,
Pump receipt attached ✓
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Alway5 working for a safer(ma neaitnier eommunii
H:\WEB\EH-WQ\SEPTIC\Applications-Fortes\cert_tank_abandon.doc
• 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
ir4 e)e
' ADDRESS
PHONE DATE
SOLD BY CASH COD. CHARGE ON ACCT. MDSE.RED
QTY TIME DRVR. DESCRIPTION PRICE AMOUNT
INT.
;<61)
3,•15 (0..neeifIt
OPIK
•
TAX
RECEIVED BY 4
TOTAL
, 6 118
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