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N ECEOVED <br /> iviAlJAN162018c <br /> Existing System Evaluation Report for Onsit ���-®t���evs����-,�� <br /> � <br /> ya <br /> �- Wastewater Systems I Ss-cpc�(7)Y2, <br /> 7 <br /> State of Oregon Department of Environmental Quality <br /> Stab of Oregon <br /> Department m Onsite Program <br /> Environmenal 165 East Seventh Ave, Suite 100 <br /> Oudiy <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 /> http://www.orecion.clovIDEQPNCl/paqesibrisitelsepticsmart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Travis&Jackie White Telephone: (503)551-9891 <br /> Site Address: 5649 Riverdale Rd. S. City: Salem Zip Code:97302 <br /> County: Marion Lot Size: 2.0 Acres/Square Feet(circle units) <br /> Legal Description: Croisan Riverdale Acres FR Lot 18 aka T8S, R4W,WM, Sect.13,Tax lot 2400 <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 :0 If unoccupied,,for how long has it been vacant? 2.5 months <br /> Was this section completed by the evaluator because own or agent was unavailable? Yes <br /> The above information is true and to thebest of my knowledge:_ <br /> 0//Zif / zo 1 . .Info gained from seller Via telephone call. <br /> Date(MMLDD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Mitchell Padilla. <br /> Certification: <br /> ❑ Installer ❑ 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: NAWT #13761T <br /> Business name King's Pumping Service Email kingspumping@gmail.com <br /> Business address PO Box 1037, Dallas, OR 97338 Phone(503)831-0104 <br /> Date of Evaluation: 01/2,/2017 (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 /> "7:("1,"2 A f-•-•- -- <br /> ate(t MIDD/YYYY) ignature ofQ Septicy <br /> ualified System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />