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: <br /> 01-40 -00r1(01-40-riv <br /> Existing System Evaluation Report for Onsite, 11 <br /> LJ T�i <br /> t Wastewater Systems <br /> mtraa - <br /> y <br /> DEQz,loy 2 0 MOState of Oregon Department of Environmental Quality <br /> State `,�ntof. Onsite Program <br /> c"wPU"a"ta' 165 East Seventh Ave, Suite 100 CCU'° 1 <br /> ty `„ <br /> Quail ✓ C`; ",l <br /> Eugene, OR 97401 IL ',,i��: :',1S-�ECTIO <br /> Please answer the following questions completely. Do not leave any blank responses.Write unknown if <br /> unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information, and please ._ <br /> visit:http://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers):er (� Telephone: <br /> Site Address: i-5 Ci NtWIt \ City: ��J Zip Code: <br /> County: Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system (years) Is there a service contract for system components? <br /> Date the septic tank was last pumped (please attach receipt if available) <br /> Number of people occupying dwelling If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? <br /> The above information is true and to the best of my knowledge. <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Richard Westerlund-- NAWT 124931TC <br /> Certification: <br /> ❑ Installer ❑ Professional Engineer <br /> D Maintenance Provider ❑ Environmental Health Specialist <br /> ❑✓ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 33013 <br /> • <br /> Business name Ace Septic and Excavating Email office@ace-septic.com <br /> Business address PO Box 9177, Brooks, OR 97305 Phone 503-393-1033 <br /> Date of Evaluation: 4 /66 (2020 (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OA' 40-071-0155. <br /> iJ Jam`. 2 2r <br /> . .L.i . � _ ill! i �J <br /> ate(MM/ D/YYYY) <br /> .lt. a .J/ignature of Qualified Septic System Evaluator ' <br /> Page 1 of 8 Updated 12/29/2016 <br />