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Existing System Evaluation Report for Onsite <br /> p tell Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> steof ,. <br /> r;:g entof Onsite Program <br /> Environmental- 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 <br /> visit:http://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): /YJr Feet'i S Telephone: <br /> Site Address: ///S / .& h ei L6 fL,City: iptyAS Zip Code: <br /> County: rp/e 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 owner 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): Richard Westerlund--NAWT 124931TC <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: 33013 <br /> Business name Ace Septic and Excavating Email office©ace-septic.com <br /> Business address PO Box 9177, Brooks, OR 97305 Phone 503-393-1033 <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 /> /2 ?-a of <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />