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a <br /> A Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> ®Eta <br /> s+a.ao ; State of Oregon.Department-:of Environmental.Quality <br /> Onsite Program <br /> a"ftwoffigway 165 East Seventh Ave, Suite 100 <br /> Eugene, OR 97401 <br /> Please answer the following <br /> 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/deck/Residential/Pages/Septic-Smartaspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(sXSellers): <br /> Telephone: <br /> site'.:Address:760 Grandview Ave <br /> City:Scotts Mills Zip code:97375 <br /> county:Marion 1.56' <br /> Lot Size . Acres/Square Feet(circle units) <br /> Legal.Description:. <br /> p NO <br /> Age of wastewater treatmentsystemN/A (years) Is there a service contract for systemcomponents? <br /> Date the septic tank was last, 2022 <br /> piped (please attach receipt-if available) <br /> Number of people occupying dwelling If unoccupied,for how long has it been vacant? 1.4 years <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) <br /> Signature of Owner,or agent if present • <br /> Name of person performing;evaluation(please.print):Charlie Bennett <br /> Certification: <br /> El Installer <br /> Maintenance Provider En[DIProfessional Engineer <br /> 0✓ National Association of Wastewater Technicians ❑ Waste <br /> errtSl Health ialstSpecialist <br /> 0 Other:DEQ 0 Waste Water Specialist <br /> Q approved in writing(please describe) <br /> Certification Number. i 3307, M440, 1.3268itc <br /> Business name Bennett Septic Serice LLC Email Bennettsepticservteelic@gm2iilcom <br /> Business address PQ Box 551 Molalla OR 97038 <br /> Phone50S"829-4452 <br /> Date ofEvaluation:01/05/2022 <br /> I hereby certify,by my signature,that I meet all of the.qualifications required to <br /> 9 �q � perform, wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> 01/O5/2022 <br /> Date(MM/DD/YYyY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />