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ab` 7 55 <br /> Existing System Evaluation Report for Onsi eat <br /> Wastewater Systems <br /> Y NMI C� try ^� <br /> S Sr i NO 2[�J 2023 <br /> .d State of Oregon Department of Environmental Quality <br /> S''a>z of Ore9an <br /> oe nn Onsite Program MARION COUNTY <br /> Environmental 165 East Seventh Ave, Suite 100Duality <br /> au,�l���,�� � � ,Tl�f�! <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-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property O�vner(s)(Sellers): Cyr" Telephone: 6-03 S' g144) <br /> lam' <br /> Site Address: 5o ` I u City: c,54 Zip Code: -"/? <br /> County: IN 4,14 h Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system l q (years) Is there a service contract for system components? la o <br /> Date the septic tank was last pumped II/7-0/737(please attach receipt if available) <br /> Number of people occupying dwelling Z If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? w� <br /> The above information is true and to the best of my knowledge. <br /> 2-47 <br /> Date(MMJDD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): <br /> Certification: <br /> 1:4‘. Installer ❑ Professional Engineer <br /> Maintenance Provider ❑ Environmental Health Specialist <br /> 0 National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved lavvriting(please describe) <br /> Certification Number: <br /> Business name k41)'I1 1)c61 r V1 Email 4if- ii U1 0146 L o`/16 15i+.1 Jr/- <br /> Business address 76g0 )11ti51lI2 ;r (JJ y SC Phone 5O3 '576-732 <br /> Date of Evaluation: 11 {, (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 340-07 155, <br /> 21-z3 <br /> Date(MMMM/DD/YYYY) Signature of Qua ified Septic System Ev for <br /> Page 1 of 8 pdated 12i29/2016 <br />