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g-6b5 185 <br /> a <br /> Existing System Evaluation Report for Onsite <br /> EARJUCIoN2c0110:u3N - � <br /> Wastewater Systems <br /> DEQ BUILDING INSPECTION <br /> Stateaoreg <br /> State of Oregon Department of Environmental Quality <br /> of Onsite Program <br /> Envftnmentl 165 East Seventh Ave, Suite 100 <br /> away <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 /> httb://www.orecon.dovided/Residential/Pades/Sentic-Smartaspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Telephone: <br /> Site Address:4196 Roberts Ridge City: Salem Zip Code:97306 <br /> County: Marion Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system (years) Is there a service contract for system components? <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 /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): <br /> Certification: <br /> ❑✓ Installer ❑ Professional Engineer <br /> ❑ Maintenance Provider E Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 1-2290 <br /> Business name Carl's Septic LLC Email eric.carlsseptic@gmail.com <br /> Business address 4742 #147 S Liberty Rd, Salem, OR, 97302 Phone503.910.6329 <br /> Date of Evaluation:6/8/23 (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 /> 6/8/23 [Digitally Signed Eric Zade] <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />