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� s <br /> � isT� - U` <br /> Existing System Evaluation Report ford [I-Onsite ►� <br /> Wastewater Systems <br /> MAR 13 2023 <br /> State of Oregon Department of Environmental Quality <br /> State oiOregon MVIARION COUNTY <br /> Department of Onsite Program <br /> Environmental <br /> 165 East Seventh Ave, Suite 100 BUILDING INSPECTION <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.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information:Property Owner(s)(Sellers): Z.fl tryei Nv l zso 1`1_ Telephone: 3-(o2 bd0 ,6-1. <br /> Site Address: 18906 Butteville Road NE City: Aurora Zip code:97002 <br /> County: Marion Lot Size: 31.76 Acres Acres/Square Feet(circle units) <br /> Legal Description: 041 W30 00700 <br /> Age of wastewater treatment system (years) Is there a service contract for system components? ifV'u <br /> Date the septic tank was last pumped bRitr:2,p(please attach receipt if available) <br /> Number of people occupying dwelling 1, 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 knowledg <br /> Date(MM/DD Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Bobby Anderson <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: R M-173 <br /> Business name American On Site Email AOSSEPTICS@YAHOO.COM <br /> Business address 31881 S Hwy 213, Molalla OR 97038 Phone503-829-7600 <br /> Date of Evaluation:03/09/2023 (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 /> 03/09/2023 <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated-12/29/2016 <br />