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Existing System Evaluation Report for On = :E3 <br /> (� <br /> Wastewater.Systems <br /> State of Oregon Department of Environmental Quality AUG.seaasoaaro <br /> 4 20Z3Le: <br /> o Onsite Program �ARIQN c., <br /> cmay - 165 East Seventh Ave,Suite BUILDING INSPuE AirO P <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 /> \visithttpSwww.aregon.gov/deq/ResidentialIPages(SepIic Smart.aspx <br /> • <br /> Septic System Owner-Provided Information: <br /> ie <br /> Property Owner(s)(sellers): ._ OV(-11• Telephone: <br /> Site dress: (c 2 51 L to la o IoLuv- PLAVI l' City: b ux Zip Code:`t-i c <br /> County: I ; -. Lot Sim: 0.1 Z- Acres/Square Feet(circle units) <br /> LegatDescripttont S:".b tAxt., 4 - 104- 2 Lai- fill A (D5(W2.511Dct tkat cen <br /> Age of wastewater treatment system (years) Is there a service contract for system components? IOC) <br /> Date the septic tank was last pumped, LI( (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 unwell c? I e5 <br /> The above information is true and to the best of my knowledge. <br /> tr I i9 <br /> Date(Mlvl DIYYYY) Signature f er,cr agent if present <br /> Name of person performing evaluation(please print): Y-,;C i a_Le l'a <br /> C ;£nation: <br /> 11 Installer 0 Professional Engineer <br /> Maintenance Provider <br /> ,. : ❑ ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians 0 Waste Water Specialist <br /> Other:DEQ approved in writing(please describe) <br /> Certification Number: "r I t-1 1 <br /> LLC <br /> Business name E -jC+1,t, CE1 Pi ft i reiEmail Ie e n co.r at-Iry e'1 t t]yt?- aN "+ i - <br /> Business address �i 4-s2 MI _ Phone 47 ''S!G-�� <br /> Date of Evaluation_ tai/i ,m..DDIYY'YY) <br /> l� <br /> I hereby certify,by my signature,that I meet all of the qualifications required a perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 349-071-I1155. <br /> • Q (tl8 : <br /> � I a ( 1;► Y'Yl'Y) Signature of Q ed ptic System Eval for <br /> Page 1 of 8 Updated 12/2912016 <br />