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• <br /> Ex st ng System Evaluation Report for Onsite <br /> Wastewater Systems <br /> State of Oregon Department of Environmental Quality <br /> s� acn5x� <br /> oe oE Onsite Program <br /> E"5.1.3 ihul 165.East Seventh Ave, Suite 100 <br /> fhaGry. <br /> Eugene, OR 87401 <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 i'visr w oegon:govidegiResicientiai'Pages/Septic-Smart:aspx <br /> • <br /> Septic System Owner-Provided Information: <br /> Property Oivner(s)(Sellers): . . , Telephone: <br /> Site Address: G o 1 c- 6 c o City: Sky401,1 . Zip Code: <br /> County:, jmi'l Lot Size: Acres/Square Feet(circle unit,) <br /> Legal Description` _ <br /> Age of wastewater.treatment system (years) Is there a service contract for system compu zents'1 <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 /> 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 knowledge. <br /> ` <br /> Date(MM;DD/Y YYY) Signature of Owner,or agent if present <br /> Name of person perforiaing evaluation(please print);. <br /> Ce ifrcation: <br /> [A Installer ❑ ProtesSional Engineer <br /> ❑. M,aintenancc Provider ❑ Fnviionmental Health Specialist <br /> 0 National Association of Wastewater Technicians 0 Waste Water Specialist <br /> ❑ Other.DEQ approved in citing(p',asc describe) <br /> Certification Number: 34313 <br /> Dram <br /> Business name / '` ' j9// Email 44 Or Cjyva), - <br /> r .t'� � r (ay Si- CJ�fra 6(z <br /> Business address bQ 0a ( rlisa_ Phone 15-e -37d-732 r <br /> —T <br /> Date of Evaluation: J'tG��i� ( IM DDiYYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to pet•forin_onsite wastewater <br /> system evaluations iri tbe.state of Oregon pursuant to.OAR 340-07. 155. <br /> Date(tit /DD/YYY Y) Signature of Qua ifled Septic System Ev: to, <br /> Page 1 of 8 "Updated 12129/20l6 <br />