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3 U ,- o o3(.4 (0 1 -ocU r '- <br /> .�r <br /> Existing System Evaluation Report for Onsite NOV 20 2020 <br /> Wastewater Systems ) IIL®Ii ON COUNTY <br /> G INSPECTION <br /> r <br /> . State of Oregon Department of Environmental Quality <br /> Sta*clOregon <br /> Departmental Onsite Program <br /> Environmental 165 East Seventh Ave, Suite 100 <br /> Quality <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/Septi;-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers):©OA Old iea.it De414 Telephone: 6-03-Sle oc.c7 <br /> Site Address: 110 NZ 0499ttbJ 141 City: 1...VOrk5 Zip Code:45/73SY <br /> County:444nd VI Lot Size: .37 Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system 5f6 (years) is there a service contract for system components? AV, <br /> Date the-septic tank vas--last Dui aped—L� 2.20-(please-auaeh reeeiipt-i availablc) <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? NU <br /> The above information is true and to the best of my knowledge. <br /> (�-- <br /> lo'Zvzv <br /> Date(MM/DD!YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): <br /> Ce cation: <br /> Installer ❑ Professional Engineer <br /> 0 Maintenance Provider ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ <br /> Other:DEQ approved inwritinn(please describe) <br /> Certification Number: 1`'1Z5 7 <br /> Business name , .4w64 �Aiyl Email AG4�oYl Ou a:eaCo €b+./ 4- <br /> rr�y 54 ^ 01z <br /> Business address?j!O O tkQ$ht s r g7317 Phone <br /> Date of Evaluation: � 1011 / (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 340-07 155. <br /> Date(MMIDD/YYYY) Signature of Qu. ified Septic Systcm Ev for <br /> Page 1 of 8 pdated 12/29/2016 <br />