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. 12- o OIWO—A1itt4 <br /> JUN 13 2010 <br /> le <br /> Existing System Evaluation Report for Onsite <br /> �� �; t' <br /> Wastewater Systems BUILDING INSPECTION <br /> DEQ <br /> S eolO , <br /> State of Oregon Department of Environmental Quality <br /> Department 6, Onsite Program <br /> en"'"Nnenil 165 East Seventh Ave,Suite Otality <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 visit <br /> http://www.oreaon.00v/deg/Residential/Pages/Septic-Smart.aspx. <br /> Septic System-Owner-Provided Information: <br /> Property Owner(s)(Sellers): Brian Sater Telephone: <br /> Site Address:940 Patureland Ln SE City: Salem Zip Code:97317 <br /> County: Marion Lot Size: 1.52 Acres/Square Feet(circle units) <br /> Legal Description: CAPITAL CITY FRUIT FARMS,LOT FR 37,ACRES 1.52,REAL M.H.:WAS X166826:EM484 <br /> Age of wastewater treatment system (years) Is there a service contract for system components?��� <br /> Date the-septic tank was last pumped 6-8-18 (please attach receipt if available) <br /> Number of people occupying dwelling 4 If unoccupied.for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? Yes <br /> The above information is true and to the best of my knowledge. <br /> Date(Mivl/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Josh Hansen <br /> • <br /> Certification: <br /> ❑✓ Installer 0 Professional Engineer <br /> ❑J Maintenance Provider 0 Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist • <br /> 0 Other:DEQ approved in writing(please describe) <br /> Certification Number: 38968 , M271 <br /> Business name Oregon Sewer&Drain LLC Email josh@oregonsewer.com <br /> Business address PO Box 1282 Silverton, OR 97381 Phone 503-874-9414 <br /> Date of Evaluation: (M,M/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications requited to perforn onsite wastewater <br /> system.evaluations in the state of Oregon pursuant to OAR 340-071-015. <br /> 6-8-18 Imo. <br /> Date(MM/DD/YYYY) Sig �tiro.o 0 uahhe Septic System Evaluator <br /> Page 1 of/ Updated 12/29/2016 <br />