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Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> State ofn <br /> ,°,,,,,"�°,, Onsite Program <br /> o 165 East Seventh Ave, Suite 100 <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 visit <br /> http://www.oredon.qov/DEQ/WQ/cadesionsite/septicsmartaspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Telephone: <br /> Site Address: 20687 Oregon 99E City: Aurora Zip Code:97002 <br /> County: Marion Lot Size: 3.26 Acres Acres/Square Feet(circle units) <br /> Legal Description: 041 W13C 00500 <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 own 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): Bobby Anderson <br /> Certification: <br /> ❑ Installer ❑ Professional Engineer <br /> 0 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: R M 173 <br /> Business name American On Site Email aosseptics@yahoo.com <br /> Business address 31881 S Hwy 213 Molalla OR 97038 phone503-829-7600 <br /> Date of Evaluation:09/15/2022 (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 /> 09/15/2022 ► ' <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />