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,p,-00 V ` <br /> D EC-E <br /> JAN 2 5 2021 , , <br /> Existing System Evaluation Report for Onsite <br /> !viririi<. N COUNTY <br /> Wastewater Systems BUILDING INSPECTION <br /> DEQ State of Oregon Department of Environmental Quality <br /> stakimp„,;,,°,.,,,"�°a Onsite Program <br /> 165 East Seventh Ave, Suite 100 <br /> Ouslity <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.oregon.gov/dea/Residential/Paaes/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Oa(' 11 gt-CS ). Telephone:503--963-Sm81 <br /> Site Address: / / Lc2.Li5a $t City: ea_7 .5 Zip Code:�f-7-3v <br /> County: �C 1%o// Lot Size: CP , � 6o C fesIS uare Feet(circle units) <br /> q <br /> Legal Description: of 3 2 90 <br /> Age of wastewater treatment system / U' (years) Is there a service contract for system components?///12 <br /> Date the septic tank was last pumped/0/z6/�m(please attach receipt if available) <br /> Number of people occupying dwelling C] If unoccupied,for how long has it been vacant?/9cu'7c/ V'e <br /> Was this section completed by the evaluator because owner or agent was unavailable? /',oS <br /> The above information is true and to the best of my knowledge. <br /> ®///,�/ O:', / <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): R.„ So✓i <br /> Certification: <br /> a Installer ❑ Professional Engineer <br /> • Maintenance Provider 0 Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 37 Z.Z 7- / /" <br /> Business name /}2 So,-7 5-^vi��/ 1..L-C Email r /'ho125eO i,1, " -c <br /> Business address /d SAC /1,//c , O , ` 3 6 Phone Sm3079 4' /� <br /> Date of Evaluation: eD/ / V ---G"2-) (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 340-0077711�0155. <br /> rD/ i - �-,mz -/ - � <br /> Date( /DD Signature of ualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />