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Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> State of Oregon <br /> Department of Onsite Program <br /> Envimmer" 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://www.oregon.govideq/Residential/Pages/Septic-Smartaspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): c)etli f 1,13 S LEV\15 Telephone: 55-11-4• 7 141 <br /> Site Address: sciPt tj \/4c-ten-- Po i yZt Rc City: S ubit rhtip Zip Code: 1.j 5 <br /> County: Mar'ilj rt Lot Size: •64 CD Square Feet(circle units) <br /> Legal Description: 0% 1J La A 0 L(000 <br /> Age of wastewater treatment system 15 j (years) Is there a service contract for system components? i:'10 <br /> Date the septic tank was last pumped 4-1%-l$ (please attach receipt if available) <br /> Number of people occupying dwelling If unoccupied,for how long has it been vacant? idl y <br /> Was this section completed by the evaluator because owner or agent was unavailable? . l eZ <br /> The above information is true and to the best of my knowledge. <br /> a-c6. -lot <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Nick Homutoff <br /> Certification: <br /> ❑ Installer ❑ Professional Engineer <br /> ❑✓ Maintenance Provider ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> D Other:DEQ approved in writing(please describe) <br /> Certification Number: RM 41 <br /> Business name Farmers Septic Company Email farmerssepticco@aol.com <br /> Business address 15127 Evans Valley Rd NE, Silverton OR 97381 Phone 503-873-3344 <br /> Date of Evaluation: I Ck. (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 /> 'S Lci <br /> Date(MM/DD/YYYY) Signature of Quali ie I ep u c System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />