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rECENE11 <br /> Existing System Evaluation Report for Onsite 3014 20 <br /> Wastewater Systems <br /> DECi <br /> _ - State of Oregon Deparintein of Environmental Quality <br /> Onsile Program <br /> Erit;'3ira76*' 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 /> visithdp://wvyworegon.govideq/ResidentialiPages/Septio-Smart.aspx <br /> Septic System Owner Information: <br /> Pmperty Owner(s)(Seliers): 1<-1--rkPatn-lk Telephone: <br /> 46 hi` Sanbarni-lity <br /> Site 9 90 kidress; city: Idanha Zip Code: <br /> county:.Marion Lot Size; Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastevrater treatment system (years) Is there a service connect for system components? <br /> Date the septietank Was last pumped (please attach receipt if available) <br /> Number of people Occupying dwelling If Imaccupied,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 liMOWlette. <br /> Date(MM/DD/M()) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Richard Westerlund—NAVIff 12493ITC <br /> Certification: <br /> Installer • 0 Professional Engineer <br /> Maintenance Provider , Etrvironmentat Ilealtb Specialist <br /> 1:1 '.National Assaciation cif:Wastewater technicians Waste Water Specialist <br /> -0 .2 Other.DF.O approved in writing(please describe) „ <br /> Certification Number: 33°13 <br /> Business.aime SePtiP and Excavating Email nffide©ane-sentic.onm <br /> Business addttss PO Box 9177,Brooks,OR- 97305 ?haat 503-393-1033 <br /> Date ofEvaluation: ilD tOiLl (MIVI/DDIYYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications requited to perform onsite wastewater <br /> system evaluations in the state of Ort%nn pursuant AR 40 7i-0155. - <br /> I:35/W 7-071-1 - <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 1249/2016 <br />