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Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> , - State of Oregon Department of Environmental Quality <br /> Safe of Oregon <br /> D IO Mof Onsite Program <br /> Envirclunenw 165 East Seventh Ave, Suite 100 <br /> Quality <br /> Eugene, OR 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 <br /> visit:http://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Telephone: <br /> Site Address: 13039 Bethlehem Dr. NE City: Gervais Zip Code:97026 <br /> County: Marion 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): Paul Hardman <br /> Certification: <br /> ❑✓ Installer El Professional Engineer <br /> ❑✓ Maintenance Provider El Environmental Health Specialist <br /> El National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: R M 193, INS 13081 <br /> Business name Top Notch Home Inspection,LLC Email paul.hardman63@gmail.com <br /> Business address 16415 S Wayne Dr. Oregon City, Or 97045 Phone971-266-7801 <br /> Date of Evaluation: 10/10/2022 (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 OAR 340-071-0155. <br /> 10/10/2022 Paul Hardman <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />