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Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> ® Q State of Oregon Department of Environmental Quality <br /> ea, Onsite Program <br /> eTM ^ ' 165 East Seventh Ave, Suite 100 <br /> outhty <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:/Iwww.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Vanessa Riley Telephone: <br /> Site Address: 23397 Santiam Way SE City: Lyons Zip Code:97358 <br /> County: Marion Lot Size: 0.85 Acres/Square Feet(circle units) <br /> Legal Description: 092E17BA00700 <br /> Age of wastewater treatment system 16 (years) Is there a service contract for system components? no <br /> Date the septic tank was last pumped 4-5-22 (please attach receipt if available) <br /> Number of people occupying dwelling unk If unoccupied,for how long has it been vacant? unk <br /> Was this section completed by the evaluator because owner or agent was unavailable? Yes <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): Josh Hansen <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: RI 761, RM 150 <br /> Business name Oregon Sewer& Drain LLC Email Josh@oregonsewer.com <br /> Business address PO Box 1282, Silverton, OR 97381 Phone 503-874-9414 <br /> Date of Evaluation: 4-5-22 (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 /> 4-7-22 <br /> Date(MM/DD/YYYY) Signature o Q alified S ptic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />