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• <br /> /9%4 Asa <br /> i'.ECEBVE <br /> Existing System Evaluation Report for Onsite JUN 9 <br /> i 3 208 <br /> n r Wastewater:Systems <br /> • <br /> EState of Oregon Department of Environmental.Quality <br /> Onsite Program <br /> : -_ ; 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 <br /> visithttp://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Telephone: <br /> Site Address: 11556 McClellan Ln SE City: Aumsville Zip Code:97325 <br /> County: Marlon Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: 092W 1.3DA01100 <br /> Age of wastewater treatment system 1995 (years) Is there a service contract for system components? no <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 /> • <br /> Name of person performing evaluation(please print): Richard Westerlund--NAWT 124931TC <br /> • <br /> Certification: a e•Se i Col A 0NI-3 <br /> 0 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: 33013 • <br /> Business name Ace Septic and Excavating Email office©ace-septic.com <br /> Business address PO Box 9177, Brooks, OR 97305 phone 503-393-1033 <br /> Date of Evaluation: S\b\ 2/ (MMIDD/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 71-0155. <br /> `J1 � -t4 ,cborte9- <br /> D e D/YYYY). Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/20]6 <br />