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2 g— 0-o li G Zt-I-(Ai Li <br /> ECEUVEr <br /> MAY 31 2023 <br /> '= Existing System Evaluation Report for Onsite MARIOI� COUNTY <br /> A-Try BUILDING Ih1Sl�,;,�t:1'1 T Wastewater Systems <br /> a .. :State of Oregon Department of Environmental Quality <br /> s�oro <br /> ,,,,�,,,,, Onsite Program <br /> EmU"nmeMar 165 East Seventh Ave, Suite 100 <br /> 1 <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-Smariaspx <br /> Septic System Owner-Provided Information:\ <br /> Property Owner(s)(Sellers): 2 CYAN\ On el Telephone: <br /> Site Address: \'1-(62.) \Ca(t V\.5� City: IUONL.( Zip Code:°fl Pl <br /> County: U.Cld\O(\ Lot Size: . V Acres/Square Feet(circle units) <br /> Legal Description: Q`1 RIM 2..v �d� V1 <br /> Age of wastewater treatment system �1Q (years) Is there a service contract for system components? <br /> Date the septic tank was last pumped (plcase 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 /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Richard Westerlund—NAWT 124931TC <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: 33013 <br /> Business name Ace Septic and Excavating Email office@ace-septic.com <br /> Business address PO Box 9177, Brooks, OR 97305 Phone 503-393-1033 <br /> Date of Evaluation: .Os 4.5 `3023 (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 OAR 3 0- 71-0 55. <br /> 1 Zoz. re5 7i <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated I2/29/2016 <br />