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Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> DE.Q State of Oregon Department of Environmental Quality <br /> a Onsite Program <br /> 5 . 1` <br /> Eugene, OR.97401 <br /> Please answer16 the fallEasfowing,questionsSeventhAuerSui#e completCharity <br /> 00ely. 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:thwuw.oregon.govtdec/R.esidentiat/Pages!Septic-Smart.aa <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): I i v' t Pixerts L i/cuelpV Telephone: 60 -71O-O7$'O <br /> Site Address:l 5 Lcr t'g`n C@v1k{ City:. 5;1veAcyt . Zip Code:97381 <br /> County: 1 t•.-r1 Lot Size: • I 'Square Feet(circle units) <br /> Legal Description: 0 (;1\ V 2. .0 0 U_1'4I00 <br /> Age of wastewater treatment system ml4v1e*.(3ears) Is there a service contract for system components? flO <br /> Date the septic tank was last pumpeduvtit4wlgatA. (please attach receipt if available) <br /> Number of people occupying dwelling + If unoccupied,for how long has it been vacant? A,tf4. <br /> Was this section completed by the evaluator because owner or agent was unavailable? .Ye5 <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): Jeremiah Horntitoff <br /> Certification: <br /> Installer ❑ Professional Engineer <br /> ❑ 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: RI962 <br /> Business name.Farmers Septic Company Email farmerssepticco@gmail.com <br /> Business address PO Box 1392; Silverton, OR 97381 phone 503-873-33444 <br /> Date of Evaluation:_O'7-c S- J C? t( (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 /> 0-7- 5~ +./0,Rleird-'77.' .Y4 <br /> Date 1M/DD/YYYY Qualified Se stem Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />