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ti- Existing System Evaluation Report for Onsite <br /> eivi Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> Onsite Program <br /> owe, 165 East Seventh Ave,Suite 100 <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-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Jeff Kohl Telephone: 503-798-2232 <br /> Site Address: 5443 Sunnyview Rd. City: Salem Zip Code: 97305 <br /> County: Marion Lot Size: .46 Acres/Square Feet(circle units) <br /> Legal Description: <br /> 072W17D 01900 <br /> Age of wastewater treatment system Q (years) Is there a service contract for system components? 4,3 <br /> Date the septic tank was last pumped o21 t (2nl please attach receipt if available) <br /> Number of people occupying dwelling 3 If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? t4,0 <br /> The above information Is true and to the best of my . iowledge. <br /> 02.1lgiAO\Ft i 1°"x <br /> Date(MM/DD/YYYY) 0 ' t Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Richard Westerlund—NAWT 12493ITC <br /> Certification: <br /> ❑ Installer ❑ Professional Engineer <br /> 0 Maintenance Provider 0 Environmental Health Specialist <br /> E National Association of Wastewater Technicians • ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 33013 <br /> Business name Ace Septic and Excavating Email office©ace-septic.com <br /> Business address PO Box 9177, Brooks, OR 97305 Phone 503-393-1033 <br /> Date of Evaluation: U Z1 I,q, Z-O 1 q (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 0 340-071-0155. <br /> oz / I q /2_o I a iVik4rr# t ei3 JL <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />