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S � <br /> Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> �,°,.,ffl°°,� Onsite Program <br /> 165 East Seventh Ave, Suite 100 <br /> Melly <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.oreoon.qov/DEQNVQ/pades/onsite/septicsmart.asox. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Telephone: <br /> Site Address: 9663 Jackson Hill Rd 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 own 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 /> O Installer ❑ Professional Engineer <br /> Q 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: RI892, RM 177 <br /> Business name Speedy Septic DBA Septic Medic Email <br /> Business address PO Box 297 Eagle Creek, OR 97022 Phone 503.663.2807 <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 /> 11/03/2023 <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />