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• <br /> EllEC-EN <br /> J <br /> FEB 06 2019 <br /> Existing System Evaluation Report for. 0 . ` (PANG I INSPECTION <br /> Wastewater Systems <br /> �.w <br /> =--- State of Oregon Department of Environmental Quality <br /> State of Oregon <br /> Department of Onsite Program <br /> Emruanmenta' 165 East Seventh Ave, Suite 100 <br /> Quay <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.oredon.dov/DEQNVQ/bacies/onsite/septicsmart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): FRANCIS GARCEAU Telephone: <br /> Site Address: 3139 JEFFERSON-SCID RD City: JEFFERSON Zip Code:97352 <br /> County: MARION Lot Size: N/A Acres/Square Feet(circle units) <br /> Legal Description: T10 R3W S12 TL1200 <br /> Age of wastewater treatment system N/A (years) Is there a service contract for system components? <br /> Date'the septic tank was last pumped 1,/21/2019 (please attach receipt if available) <br /> Number of people occupying dwelling 3 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 /> 01/22/2019 <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): CHRIS <br /> Certification: • <br /> 0 Installer 0 Professional Engineer <br /> ❑ Maintenance Provider 0 Environmental Health Specialist <br /> 0 National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: RI 746 NAWT 7942ITC <br /> Business,name RAYS SEPTIC TANK SERVICE Email <br /> Business address PO BOX 3204 Phone(541) 928-8331 <br /> Date of Evaluation: 01/21/2019 (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to perfor r r onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 341-071-0155. <br /> 01/22/2019 1 Q ' <br /> Date(MM/DD/YYYY) a attire of Qualifie. eptic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />