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/71,11-C irg41-"pi, - <br /> - - . <br /> - . - • . - - tf.t .y", <br /> •,...t.d1/41 <br /> . . <br /> -- -.::-k Existing System Evaluation. Report for Onsite • . <br /> . . <br /> .; '---:" ri Wastewater Systems . <br /> ... . DEQ. <br /> • State of Oregon Department of Environmental Quality . • <br /> • • . steacm971 <br /> • Diporemirs Onstte Program . <br /> EndWaagal • 165 East r Avenue,Suite 100 <br /> OEM • <br /> Eugene,Oregon 97401 <br /> 4, <br /> 4 Please answer the following,questions as completely as•possible.If you are unable to fill out any part of <br /> this form indicate in writing why these sections were left blank.Refer to OAR 340-071-0155.For more <br /> ,,. <br /> • . Information,visit www.oregon.goviDEOANWpage.s/onsitelsepticamart. •• <br /> . Septic System Owner-Provided.Information: ' <br /> • <br /> .Property Owner(s)(Sellers): • . _ - Telephone: <br /> ., • , Site Address:VI 1;i ia4.1e'r"-(2-. 0 - Sr?Ozglity: cl;-PO i Zip Code: • <br /> • county: rhar,-:4?r-. . Lot Size: Acres/Square Feet(circle units) <br /> • <br /> Legal Description: • Oil- ir''e'-'61•1k• <br /> ' Age of wastewater treatment system 141 (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 /> • The above information Is true and to the best of my knowledge. <br /> Date(DD/MM/YYYY) Signature of Owner <br /> . ...____,„_ <br /> • Name of person performing inspection(please print): yvt,?i(r,„. 1,3 -1->,...1 c roi 5 • <br /> Certification: _ <br /> , 0 Installer .. 0 Professional Engineer <br /> 2 Maintenance Provider • 0 Environmental Health Specialist <br /> 0 National Association of Wastewater Technicians 0 ,,,Wastewater Specialist <br /> • : D Other:DEQ approved in writing(please describe) <br /> Certification Thunber: %. 0 I 3 <br /> Business name V\C k. ca e."\-\L S er•;,vt. Email O1-CAM @ a( <br /> Business address V 6 q,D),* ci t Ti Phone k).-lo-3123 <br /> Date of Inspection: g.--7.--,0 3 (DD/MM(YYYY) <br /> . .• • <br /> • <br /> thereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater ...:. <br /> system inspections in the state of Oregon pursuant to OAR 340-071-0ISS. <br /> 7 ,-013 - Aiv,,,101iir - <br /> • <br /> Date(DDAVIMPNYY)' . .-... <br /> Sigtaturi of Qualified Septic System Inspector <br /> - .;.. <br /> • '• i <br /> • <br /> ,:. .'" •• <br /> ,h. <br /> . <br /> ': .'- <br /> • <br /> , • •• ' 4 <br /> / <br /> r '• " <br /> -• - <br /> - • • Pagi <br />