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Existing System Evaluation Report for Onsite <br /> eal Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> as=;,o,.,,'0d Onsite Program <br /> 165 East Seventh Ave,Suite 100 <br /> wry <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.gov/deqlResidential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(sXSellers): Budlong Family Trust Telephone: <br /> Site Address: 12255 Budlong City: Mill City Zip Code: 97360 <br /> County: Marion Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system (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/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Richard Westerlund—NAWT 12493ITC <br /> Certification: <br /> ❑ Installer 0 Professional Engineer <br /> ❑ Maintenance Provider 0 Environmental Health Specialist <br /> m 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: 01, 13I /Zo ig (bM4/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 toO 0-011-0155. <br /> 81/31 /7_014 Ar��' rfirA /zW <br /> Date(M1t4/D ) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />