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I. <br /> , <br /> Existing System Evaluation, Report for Onsite <br /> Wastewater Systems <br /> ,-. -- State:of Oregtin Depathnent.of Erivironmental Quality <br /> OnsiteFrpgram <br /> -gnYlmnrae-Ital 165 East Sexist-1th Ave, Suite 100 <br /> thnifty <br /> ugene, OR 071101 <br /> Please answer the folbwing questions completely..Do not leave any blank responses.Write unknown if <br /> unknown. Refer to Oregon.Administrative Rule 340-071-.01.55 for more information, and please <br /> visithttplANweLoregon.govideceResicientialiPaget/Septic-Smatiaspx <br /> Septic System Ormer-Provided!Ilia <br /> Property Owner(s)(Sellers): <br /> Telephone: <br /> Site Addr-ess: (CI 1 An lAe*It I4;il R eA City-.. ۥVrer60.1 zip:code: ..6.cn -z <br /> County:/1114.1741 Lat Size: Ca 25: ap'Square Feet(circle units) <br /> Legal Description: <br /> Age of waste-water tcatment system (years) is there aserviec contract for system components? <br /> Date the septib tank Was last-pumped (please attach receipt if available) <br /> Number of people oecupying dwelling if unoccupied,for how tone: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(ivilvtinDisTYYY)- <br /> Signatum of Owner,or agent if present <br /> Name ot person performing,evaluation(please print); <br /> Certification: <br /> rtistwier 0 ProfessiotatEneineer <br /> 0 Maintenance Provider n Environinental Health Specialist <br /> .n National Association of Wastewater Technicians El Waste Water Specialist <br /> 0 Other:DEQ 41prtwed in wridng(-please describe) <br /> Certification Nurnber: P.I.g5 7 <br /> Business name 4C:+ten bV%.i IA. Email s:If...ackCciAcirip1/4 neloytek.k. tem <br /> . <br /> c/ <br /> Business address 34:10 gagt-hili7 0:04-j- -6......- Phone 5173--S7C1,--7 2-1 <br /> _ <br /> Date of Evaluation:MA//2021/ (MWDDArYYY) <br /> I hereby tertifYt by/HY s'igtlature,that I meet all of the qualifications required to perform nsite wastewater <br /> systot evaluations in the state of Oregon pursuant to OAR 340-07' 55. i <br /> Oft[5'7014 - <br /> ------7"--)_ <br /> Date 04iVfiDDNYVYY Simature of tr-iffect Septic SY5terri Ev .for <br /> Page 1 of 8 plated 11/29120,16 <br />