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0,g 1-1-6-AGP <br /> RECEIS En <br /> JUN 1420211 <br /> Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> IDEQ <br /> State of Oregon Department of Environmental Quality <br /> sue d Oregcin <br /> Deaf- Onsite Program <br /> e 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: Chia <br /> Property Owner(s)(Sellers): Amy&Thomas Lear Telephone: 9v2 i I o .0326 <br /> Site Address: 7957 Stafney Ln NE City: Gervais Zip Code:97026 <br /> County: Marion Lot Size: 1.5 Acres/Square Feet(circle units) <br /> Legal Description: 052W11C000400 <br /> Age of wastewater treatment system 1974 (years) Is there a service contract for system components? no <br /> Date the septic tank was last pumped 2016 (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? <br /> The above information is true and to the best of my knowledge. .1 <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Richard Westerlund--NAWT 12493ITC <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 ofEvaluation: (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 AR 340-071-0155. <br /> fl u/i4 1 A4 67r '11Li rIZ. . ?VEX <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />