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CERTIFICATION OF TANK DECOMMISSIONING �'>‘..0", 9` "r40
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Address GO LP 1`' Q • _
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Property Owner Name 6-AR-1/4( IA14�(l.�� p l'�'k LL 1 ps C b Ng-) .
Septic Permit# (if applicable) 5 0 O — 21 `>
Individual/Company Certifyin Abandonment 40
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Phone Number 3co 2-).6 ( ^ 3,g15-
I certify that all sewage was removed from the septic tank and/or pump chamber
on the above referenced site by a Jeffers1 n County Certified Septic Tank
Pumper, the tank filled with soil or gravel.
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I certify that the septic tank and/or pump chamber on the above referenced sits
has been decommissioned to Washington State and Jefferson County Public
Health Requirements.
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Pump receipt attached
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PPc. 14 ( $f w i3L- * 6,,S iN511)&. SUg-Elics
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H:\WEB\EH-WQ\.SEPTIC\Applications-Forms\certtank_abandon.doc
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