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2 — GO6133 61u17i <br /> Existing System Evaluation Report for On ' 4E C iF i V F <br /> Wastewater Systems <br /> DEQ. AUG 10 2�23 <br /> State of Oregon Department of Environmental Quality <br /> =orogon <br /> �, 165Onsite Program MARION COUNTY <br /> GuaRtr 165 East Seventh Ave, Suite 100 <br /> Eugene, OR 97401 BUILDING INSPECTION <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: <br /> Property Owner(s)(Sellers): �Nm WQgihWS&,hnialee, 4F�tlS�dt Telephone: -@0.3)sriq-lq$® <br /> site Address: 2272 Matheny Rd City: Gervais Zip Code:97026 <br /> County: Marion Lot Size: `,3q Acres/Square Feet(circle units) <br /> Legal Description: 053W360000300 <br /> Age of wastewater treatment system 2004 (years) Is there a service contract for system components? no <br /> Date the septic tank was last pumped i (please attach receipt if available) <br /> Number of people occupying dwelling Li 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 /> OB a' <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 /> 0 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: c'? / L� / 2..d Z,3 (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 pttrsua to OAR 340-071-0155. <br /> 0-1 /id .f 20Z3 tZcti'3 <br /> Date(MM/DD/'YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />