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Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> ** JI*4 <br /> State of Oregon Department of Environmental Quality <br /> e=2,4• Onsite Profram <br /> ar'urro" 165 East 7 Avenue, Suite 100 <br /> csitv <br /> Eugone,Oregon 97401 <br /> Please answer the following questions es completely as possible.If you are unable to fill out any part of <br /> this form Indicate in writing why these sections were left blank. Refer to OAR 340-071-0155.For more <br /> information,visit www.ore.gon.goviDEOJWOJpagesionsfteisepticsmart. <br /> Septic System Ovincr.Provided Information: <br /> • Wept*Ow4074$04.1%-s);hael LeA „, creopriono: I <br /> site Acicireangsza. _____City: Zip Code: <br /> County:VIA-:416aLot Size: AeresiSquare Fest(circle mu.1.5) <br /> Legal Description: _ _ <br /> Age of wasMater treatment system I'M (years) Is there a service contract for system compenents? &__ <br /> Date the septic tank was last pumpeti ? (please attach receipt if available) <br /> • -Number of people occupying dwellink Z-- If unoccupied,for how tong has it been vacant? —"— <br /> The above information is true and to the best of my knowledge, <br /> Data(DDRaifYYTY) Signalize of Owner <br /> Name of person performing inspection(please print): neier <br /> • <br /> CertiftC4011: <br /> installer 0 Professional Enneor <br /> Er Maintenance Provider D. Environmennd Health Specialist <br /> National Association of Wastewater Technicians 0 Wastewater Specialist <br /> • •: O other,DEC)gproved in writing(ple,ase describe) <br /> Cextification Number <br /> Busins name jieP- Email <br /> V.1.1.1.0•M <br /> r, " <br /> Basilian j4ZZ>_12/42,:v&_ae._,_.phone <br /> Date of Inspection: (DD/MIWYYYY) <br /> • <br /> 1 <br /> hereby certify,by my signature,that 1 meet all of the qualifications required to perform onsite wastewater <br /> system hispedions in the state of Oregon pursuant to OAR 340-071-015S. <br /> /0 — A e 0146 <br /> Date(DD/MM/YYYY) • Signature of Qualified Septic System Inspector <br /> • : Paga <br />