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Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> Ltitti <br /> State of Oregon Department of Environmental Quality Statoolk Omgon <br /> Onsite Program n.. <br /> Emovninental 165 East Seventh Ave,Suite 100Quaty <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.orecon.00video/Residential/Paqes/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> • <br /> 's <br /> Property Owner(s)(Sellers): ': ,^�.Com. A fl ra.1J.ei Telephone: <br /> Site Address: 1 '7 12.LII 4b City: _g, f.r i9A. Zip Code: 7 ��( <br /> County: l CY ._ Lot Size: (, 3 Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system- — (years) Is there a service contract for system components? utO. <br /> Date the septic tank was last pumped 61. (please attach receipt if available) <br /> Number of people occupying dwelling . If unoccupied,for how long has it been vacant? f, <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. y <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): -..e.,,, iL, 1 e� <br /> Ce fication: <br /> [r Installer ❑ Professional Engineer <br /> 0 Maintenance Provider ❑ Environmental Health Specialist <br /> 0 National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe)• <br /> Certification Number: .T 3 ._5'7 <br /> • <br /> Business name i b,r •�� to', S Email �c �6) s i77S-& <br /> Business address 7 C.. e (4•,sr�, Shone - 2-73 7/LS:;:.? <br /> Date of Evaluation: / - / - f Cj (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 /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 ` - <br />