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t' ExistingSystem Evaluation' Report for On 7P:- ECEVE <br /> r - Wastewater Systems <br /> .: DEQ AUG 18 2021 <br /> State.of Oregon Department of Environmental Quality.: MAR ON s o Program COUNTY Progra COUN. <br /> 165 East Seventh Ave, Suite 100 BUILDING INSPECTION <br /> Eugene, O R 97401 <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 visit <br /> httpa/www.oregon.gov/dea/Residential/Fades/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> 'Property Owner(s)(Sellers): Ai. .irk r 4,7G0,,'74'ter Telephone:S,p3-We> Z33m <br /> Site Address: /?-67 jorbi, �E• City:. Gc.7 Zip Code:9I34/ <br /> County ,/L2Arievi Lot Size: J2/4tei-7 Acreseouare circle units) <br /> Legal Description: �::93: :Z r 3 Z� <br /> ?°'Age of wastewater treatment system b.:A I(years) Is there a service contract for system components? (1157 <br /> Date the septic tank was last pumped e4 k (please attach receipt if available) <br /> Number of people occupying dwelling '7 _ If unoccupied,for how long has it been vacant?', �_ <br /> Was this section completed by the evaluator because owner or agent was unavailable'?:/ S <br /> :The above information:is true and to the best of my knowledge. <br /> &7-4-g/v-eP f r—� � <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Pip Li ,(47 <br /> Certification: <br /> I; Installer: 0 Professional Engineer <br /> fT Maintenance Provider 0 Environmental Health Specialist <br /> ::❑ National Association of Wastewater Technicians 0 Waste Water Specialist <br /> .:❑ Other:DEQ approved in writing(please describe) <br /> Certification Number. 3 '3 2 22 <br /> Business name. cen 5r5-1-19.- _5 'lrLe., Email r`e� ,s e� �a..)..epi„� <br /> Me <br /> Business address PO 8vpL$/ 41P.YJ 4y c " `�?3ro0 Phone 503-8 - /fl ; <br /> Date of Evaluation: �:'���.9/ / (MMIDDIYYYY) <br /> I hereby certify,by my signature,that:I meet all of the qualifications required to perform onsite wastewater <br /> :system evaluationsin the state of Oregon pursuant to OAR 340-071-0155. <br /> Date rP 7 �l '"---- <br /> Signature of. alified Septic System:Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />