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at\—1)D Ste LA <br /> RECEllvE <br /> AUG 27 2021 <br /> Existing System Evaluation Report for Onsiteg��®G �! <br /> . Wastewater Systems EcrioN <br /> DEQ State of Oregon Department of Environmental Quality <br /> smreaor <br /> O. Onsite Program <br /> eiti1"°unental 165 East Seventh Ave, Suite 100 <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.orecon.dovided/Residential/Pades/Septic-Smartaspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Michael Roantree Telephone: 503-949-7699 <br /> Site Address: 23980 Summerhaven Dr. City: Lyons Zip Code:97358 <br /> County: Marion Lot Size: 2 Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system? (years) Is there a service contract for system components? no <br /> Date the septic tank was last pumped? (please attach receipt if available) <br /> Number of people occupying dwelling 2 If unoccupied,for how long has it been vacant? Since fire <br /> Was this section completed by the evaluator because owner-or agent was unavailable? No <br /> The above information is true and to the best of my knowledge. <br /> 8/26/2021 Andrew Modine <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Andrew Modine <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: 39331 <br /> Business name Modine Construction Email andrew@moconusa.com <br /> Business address 5237 Chehalis Dr. N Keizer OR 97303 Phone 503-302-4444 <br /> Date of Evaluation: 8/26/2021 (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 /> 08/26/2021 Andrew Modine <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />