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EXISTING SYSTEM EVALUATION REPORT x EXISTING SEPTIC TANK EVALUATION REPORT <br /> Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> DEQ <br /> State of Oregon Department of Environmental Quality <br /> Onsite Program <br /> 165 East 7th Avenue,Suite 100 <br /> Eugene, Oregon 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 /> https://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers) CHRISTOPHER SEDBERRY Telephone <br /> Site Address 23534 SANTIAM WAY SE City: LYONS Zip Code: 97358 <br /> County: MARION Lot Size: 1.09 Acres-.quare Feet(circle units) <br /> Legal Description: T-95 R-2E SEC-17 TL-95 <br /> Age of wastewater treatment system N/A (years) Is there a service contract for system components? NO <br /> Date the septic tank was last pumped UNKNOWN (please attach receipt if available) <br /> Number of people occupying the dwelling 0 If unoccupied,how long has it been vacant BURNED <br /> Was this section completed by the evaluator because own or agent was unavailable? YES <br /> The above information is true and to the best of my knowledge. <br /> 2/22/2022 BY PHONE WITH CHRIS SEDBERRY <br /> Date(MM/DD/YYYY) Signature of Owner <br /> Name of person performing inspection(please print) JOSH SIMMONS <br /> Cerfification: <br /> Installer Professional Engineer <br /> Maintenance Provider . Environmental Health Specialist • <br /> X National Association of Wastewater Technicians Wastewater Specialist <br /> Other DEQ approved in writing(please describe) <br /> Certification Number: 13661ITC <br /> Business name: A&B Septic Service/Valley Septic Service Email a_b_septic@hotmail.com <br /> Business address:P.O.Box 444,Albany,Or,97321 Phone: 1-866-927-1156 <br /> Date of Evaluation: 3/9/2022 (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 /> 03/09/2022 JOSH SIMMONS <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator - <br /> Page 1 of 8 Updated 12/29/2016. <br />