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_ . . .. <br /> - . <br /> , . <br /> Existing System Evaluation Report for Onsite <br /> • Rir ,;,,og <br /> Wastewater Systems . <br /> :DE . <br /> State of Oregon Department of Environmental Quality <br /> Statio of 04egon <br /> Deminiontot Onsite Program <br /> 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 <br /> visithttp://www.oregon.govideq/Residential/Pages/Septic-Smartaspx <br /> Septic System Owner-Provided Information: <br /> .:. ' Property Owner(s)(Sellers); S\.1( Civr\ \ireAC\ Telephone: <br /> 1 .."/N.,i <br /> Site Address: 7- 0 Vk 01.3\y.) \i00, NAgyity: c' 01.1)1,ktlel Zip Code: *Re ce 723/ <br /> t 7 <br /> ,-- <br /> county: Uaivzrt, ,c:) Lot Size: 1— a kin 6.Square Feet(circle units) <br /> Legal Description: '0%2-W 02L OD\O\ <br /> Age of wastewater treatment system Vint(years) Is there a service contract for system components? V\0 <br /> Date the septic tank was,last pumped I W (please attach receipt if available). ' . ' <br /> \ <br /> . Number of people occupying dwelling I If unoccupied,for how long has it been vacant? \is.il J\P\ <br /> Was this section completed by the evaluator because owner of agent was unavailable? - \Ikii\ - <br /> The above information is true and to the best of my knowledge. <br /> . , <br /> A <br /> Date(MM/DD/YYYY) Signature of Owner,or ent if present <br /> Name of person performing evaluation(please print): <br /> Certification: <br /> 0 Installer . El Professional Engineer , • <br /> 0 Maintenance Provider ' 0 Environmental Health Specialist <br /> 121 National Association of Wastewater Technicians 0 Waste Water Specialist <br /> El Other:DEQ approved in writing(please describe) • <br /> Certification Number: NAW. 134931TC <br /> .. - . . <br /> Business name Ace Septic and Excavating, Inc. Email office@ace-septic.corn <br /> Bushiess address PO Box 9177, Brooks, OR 97305 Phone 503-393-1033 <br /> . ., 3 <br /> 11 Date of Evaluation: Q.,) f Z.7/iit)LI (MM/DD/YYYY) <br /> 1 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 0• ; 340-071-6155. <br /> - <br /> ' , Z. _ Old" ._. , - Z ' _-,. 9-IOrii "' .t. Z q <br /> Date(r "D/YyYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 I. <br /> : - <br /> ‘ .. <br /> • , . <br />