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IAI23202k <br /> 411-'D L% - -L)Y <br /> • <br /> • . Existing System Evaluation Report for Onsite • <br /> j•• • <br /> . A.i� . Wastewater Systems <br /> DE State of Oregon Department of Environmental Quality -- <br /> Onsite Program <br /> qff 165 East Seventh Ave, Suite 100 <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 Owne s ie-v Ifr)0YY'1,e, 1\1 eV`Gc ,Telephone:3 -q 9- 73 3 <br /> Site Address: _1 J NO W 0►.tA' 0% WCi City: al%\-e-t1(\ Zip Code:C1 l¶)OJ <br /> County: Olr 7 V(' Lot Size: V.8fl Acres/Square Feet(circle units) <br /> Legal Description:- 0\l?Z ou q 0012 00 <br /> Age of wastewater treatment.systemVh,i 4years). Is there a service contract for system components? Vkik <br /> Date the septic tank was last pumped (please attach receipt if available) • <br /> Number of people occupying dwelling 3 If unoccupied,for how long has it been vacant? . <br /> Was this section completed by the evaluator because owner or agent was unavailable? /✓d <br /> The above information is true and to the best of my knowledge. <br /> • C..� 3 - �02 y oY � • <br /> . Date(MM/DD/YYYY) Signature of Owner,ant <br /> Name of person performing evaluation(please print): Richard Westerlund—NAWT 12493ITC <br /> • <br /> Certification: . <br /> • <br /> •❑ Installer 0 Professional Engineer • <br /> ❑• Maintenance Provider 0 Environmental Health Specialist <br /> © National Association of Wastewater Technicians 0 Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 33013 <br /> • <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 /> Dater of Evaluation: 05 /05 / 2...023.1 (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 OAR 340-071-0155. <br /> b5/03 1'Zuz/ 11/4 4 -1Z9 t3.t -- .. <br /> Date(MlV1/DDIYYYY) Signature of Qualified Septic System Evaluator •. <br /> Page 1 of 8 Updated 12/29/2016 <br />