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Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> DE• Q State of Oregon Department of Environmental Quality <br /> State of <br /> i,, Onsite Program <br /> Envimninenill 165 East Seventh Ave, Suite 100 <br /> Ctuarity <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 /> http://www.orebon.qov/dea/Residential/Paaes/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): � rp A SD\\.00.h Telephone: S 63'1 kt V 2-7 E3 <br /> Site Address: —7 q � k4Q5 City: Zip Code:Tl3Z5 <br /> County: ► \ ri e„ . Lot Size:2-7-- (A-C-- /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 owngt or agent was unavailable? <br /> The above information is true and to the best of my knowledge. \ `� II'Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): <br /> Certification: <br /> ❑ Installer 0 Professional Engineer <br /> ❑ Maintenance Provider 0 Environmental Health Specialist <br /> El National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: <br /> Business name Email <br /> Business address Phone <br /> Date of Evaluation: (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 /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />