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Letn5 <br /> Existing System Evaluation Report for OnsiteRhC <br /> EIVED <br /> Wastewater Systems <br /> AUG 05 2024 <br /> DEQ <br /> State of Oregon Department of Environmental Quality <br /> aabacregga7 Onsite Program <br /> awftwunenta) 165 East Severrth Ave,Suite 10,0 <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 /> httn://www.oredonAovideo/ResidentialiPaqes/Septio-SmarLaspx. <br /> Septic.System Owner-Provided Information: <br /> Property Owner(s)(SeIlers): •.?, kra. Cru Telephone: (.5 OS- <br /> Site Address: 1)-a-41 S Lk -. S r City: ky -1/4...s Zip,Code: <br /> County: )144.1A-PAs0V Lot Size: Acres/Square Feet(circle units) <br /> Legal.Description: <br /> Age of wastewater treatment systenral(years) Is there a service contract for system components? ..- <br /> Date the septic tank was last pumped (please:attach receipt if available) <br /> Number of people occupying dwelling L If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator became owner or agent was unavailable? <br /> The above information is true and to the best of my knowledge. <br /> 2.. q <br /> Date(MM/DDNYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): %). <br /> Cerdfication: <br /> M- Installer Ei Professional Engineer <br /> o Maintenance Provider El Environmental Health Specialist <br /> Ef National Association of Wastewater Techticians ID Waste Water Specialist <br /> o Other:DEQ approved in writing(please describe) <br /> Certification Number: R- - <br /> Business name p 4,4e....t Email I-0,-, L4-e-s irk°e_s g-774-7g7 <br /> Business address S-77,4,--Cc,.4.4ce_ Phone <br /> Date of Evaluation: r- - (MmamfylriTY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to performnnsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> Date(MM/DD/YYYY) Signature of Qnnlified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />