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7. . <br /> g'k-0317ait) <br /> RECEIVE <br /> • <br /> AUG 23 2024 <br /> -� = Existing System Evaluation Report for Onsite <br /> itemaWastewater Systems <br /> State of Oregon Department of Environmental Quality <br /> StateofO,e on <br /> pepa,t„eaf_ Onsite Program <br /> f"virc'n"e"4a'. 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:/fwww.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Information:: <br /> Property Owner(s)(Sellers): •i `( $ '[<ELLl Sue. Telephone: E63'S O-Zs89 <br /> Site Address: , n\� . Aj\AlO" 1..k City: C)N.liti13 Zip Code:____ <br /> County: k.011 Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: \ V 22) DOJ 2M <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 /> 22--202.4 . 31E2.69-fe— <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please.print): V-.-:A(.� t,Aj.t Ii‘k.ANA <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: 330 <br /> Business name•cre 50')L •• Email 1,1 cO o (,,,Corn <br /> Business address (Moo Po l!At.Olt'\ VS Phone SC -j—I 03 5 <br /> Date of Evaluation: 0$ I Z Z/,ojk (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 t AR 40-071-0155. <br /> Alsa/v <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br /> • <br />