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° ECEiNEft <br /> Ln <br /> MAR 16 2021 <br /> IVIARION COUI( "y <br /> 91 III_.DING INSPEf-'?-iC r, <br /> Existing System Evaluation Report for Onsite g -bp -) 13 <br /> Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality Onsite Program <br /> 165 East Seventh Ave, Suite 100 <br /> Quality <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 /> htto://www.oregon.00v/DEQM/Q/paaesionsite/seoticsmart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Telephone: <br /> Site Address: 12244 Dimmick Ln NE City: Woodburn Zip Code: 97071 <br /> County: Marion Lot Size: 19.88 Acres Acres/Square Feet(circle units) <br /> Legal Description: 051W040002300 <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): Andrew Spencer <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: M-353 <br /> Business name Speedy Septic DBA Septic Medic Email shannon@speedyseptic.com <br /> Business address PO Box 297 Eagle Creek, OR 97022 Phone 503-663-2807 <br /> Date of Evaluation: 03/02/21 (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 340-071-0.1555.� <br /> 03/02/21 <br /> Date(MM/DD/YYYY) Signature of Q a i d Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />