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•• Existing System Evaluation Report for OnsiECEIVED <br /> Wtil Wastewater Systems <br /> DEQ AUG 0 6 2024 • <br /> State of Oregon Department of Environmental Quality <br /> mod• Onsite Program . <br /> enigMailltd 185 East Seventh Ave, Suite 100 <br /> Eugene,OR 97401 <br /> Please answer the following questions completely.Do not Ieave any blank responses.Write unknown if • <br /> unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information, and please Visit <br /> htto://www.orecon.00videa/Residential/Paces/SeotioSmart.asox. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Do cc5 has R. /,(1 oo Ile y Telephone: (503)781-3599 <br /> Site Address: /4-0 8'2 Pie►-St NE City: Att ro ret Zip Code: 9'76 02 <br /> P <br /> County: /Y}a Wolf. Lot Size: .2/5'9 2 S _ *Acres/Square Feet(circle units) <br /> Legal Description: Lot/6t Mock�,Si sts,±ldavgr., 6+1 We 2.DC 62 000 <br /> Age of wastewater treatment system-F(years) Is there a service contract for.system components? /ro <br /> Date the septic tank was last pumped t!d/L,i.04please attach receipt if available) <br /> Number of people dweilin , ���, <br /> p p occupying p 0 If unoccupied,for how long has it been vacant? .0.',d2.yl1-s <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. 1 <br /> 7//8C <br /> Date(MIvI/DD/YYYY) Signature of Owner,or-agent if present <br /> Name of'person performing evaluation(please print): /tief_AZ /Gv l/�C_ <br /> Certification: <br /> ❑ Installer ❑ Professional Engineer <br /> • .eMaintenance Provider' ❑ Environmental Health Specialist <br /> National Association of Wastewater Technicians 0 Waste Water Specialist <br /> ❑ Other.DEQ approveddn in writing(please describe) <br /> Certification Number: !`. P1 13.3 <br /> Business name kiate19,4 4S `0� ,le e,FA"ail 1C{a.1?4llii3G Se or CsrLD;beayPLy I. t) <br /> Business address A 0,Any 8/8 4 Dot. r 7 'J Phones-5'4.lr % Z <br /> Date of Evaluation: 7/!8 ,2 y (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 /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated I2/29/2016 <br />