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A - <br /> Existing System Evaluation Report for Onsite <br /> Wastewater Systems MAR 17 2022 <br /> State of Oregon Department of Ernfironmental.Quality MARION COUNTY' <br /> onsite Program BUILDING INSPECTION <br /> 165 East Seventh Ave,Suite 100 <br /> oitaity <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 /> visithttpliwWw.oregon,govidegiResideritial/PagesiSeptio-Smail.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): • ,2 . • Telephone <br /> Site Address: gO_ 44-Q-- City: Pela% 1 Zip Code: <br /> County 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 /> Wa.sthis section completed by the evaluator because owner or agent was.unavailable'? <br /> The above inforniation is true and to the best of ray.knowledge. <br /> Date(MWDDIYYYY) Signature of Owner,,or agent if present <br /> 'lame of person performing evaluation(please print)cation: <br /> ff. Installer LIPro*ssional Engineer <br /> 'Maintenance Provider 0 Environmental Health Specialist <br /> 0 National Association of Wastewaterleehnicians 0, Waste Water Specialist <br /> o Other:DEQ approved in writing(please describe) <br /> Certification Number: gizsi <br /> Business name 4CitttilA Drttrol Email A-.410/1 DrAti4 CO 7fticaks4 <br /> Sawn ag- <br /> Business address 4-1- Pti° rA6,14044 r Utay eiltr7 Pliant S.63 — S7a-1,74 <br /> Date of Evaluation: 10 se' 111—ZO (IvIMIDDNYYY) <br /> I hereby eertify,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 343J. lc5. <br /> 0 /61—ZA? <br /> Date(MM/DDNYYY) Sigiamrc ofQua&led Septic System EV tor <br /> Page 1 of 3 - pdated 1-2129/2016 <br /> ‘+, ; <br />