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AD0 8 � <br /> EcEllvE <br /> I AR10rj COONV <br /> BUILDINGJAN INSPECT2Q2iIORI <br /> (75q5Existing System Evaluation Report for Onsite Z l ` 2-2-2 <br /> Wastewater Systems <br /> -- State of Oregon Department of Environmental Quality <br /> riot Onsite Program • <br /> enviltflmegtA 165 East Seventh Ave, Suite 100 <br /> atrality <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 /> visit http://www.oregon.govideq/Residential/Pages/Septic-Srnartaspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): -- Telephone: 563 —77%-15 75 <br /> Site Address: 2?i SA,f7/4,4 P ity: Zip Code: <br /> County: A tin.) Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment systcm (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 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/DDIYYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): <br /> Certification: <br /> rInstaller ❑ 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: XI. 217 <br /> Business name Ac-7,,,,o -i)/240) Email J <br /> �! et.C1 G4dI- c,' r <br /> Business address 1(9 9.-0 KA.V/Aj ,( `/ 447 S Phone SO3 -'9.1Z- Ye/ <br /> Date of Evaluation: f 0/21 724.YZ1) (MMJDD/YYYY) <br /> I hereby certify,by my si;nature,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-07 55. <br /> it)�Z/ 2tiz.v <br /> Date(MM/DD/Y Y) Signature of Qua died Septic System Ev or <br /> Page 1 of 8 pdated l2/29/20]6 <br />