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EXISTING SYSTEM EVALUATION REPORT x j EXISTING SEPTIC TANK EVALUATION REPORT <br /> Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> DEQ <br /> State of Oregon Department of Environmental Quality <br /> Onsite Program <br /> 165 East 7th Avenue,Suite 100 <br /> Eugene, Oregon 97401 <br /> Please answer the tollowing questions completely. Do not leave any blank responses. Write unknown it <br /> unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information, and please visit <br /> https://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers) DORSON JACKSON Telephone <br /> Site Address 5515 SERENITY DR.SE City: SALEM Zip Code: 97307 <br /> County: MARION Lot Size: 1.21 Acres,-quare Feet(circle units) <br /> Legal Description: T: 8 R: 3W SEC: 12DB TL: 400 <br /> Age of wastewater treatment system N/A (years) Is there a service contract for system components? NO <br /> Date the septic tank was last pumped UNKNOWN (please attach receipt if available) <br /> Number of people occupying the dwelling 2 If unoccupied,how long has it been vacant <br /> Was this section completed by the evaluator because own or agent was unavailable? YES <br /> The above information is true and to the best of my knowledge. <br /> 05/20/2022 SPOKE TO DORSON BY PHONE <br /> Date(MM/DD/YYYY) Signature of Owner <br /> Name of person performing inspection(please print) RYAN TYLE <br /> Certification: <br /> �X ,Installer ! Professional Engineer <br /> Maintenance Provider Environmental Health Specialist <br /> National Association of Wastewater Technicians Wastewater Specialist <br /> j Other DEQ approved in writing(please describe) <br /> Certification Number: 13004 <br /> Business name: A&B Septic Service/Valley Septic Service Email a_b_septic@hotmail.com <br /> Business address:P.O.Box 444,Albany,Or,97321 Phone: 1-866-927-1156 <br /> Date of Evaluation: 6/16/2022 (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 /> 06/16/2022 RYAN TYLE <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />