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c <br /> Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> State at Oregon <br /> Department of Onsite Program <br /> Environmental 165 East Seventh Ave, Suite 100 <br /> Duality <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.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Telephone: $7'..5' 9,419 <br /> Site Address: b eat 4V- A tcT► L City: 5-Iver` \,()f.,Zip Code: CrIN <br /> County: f wir,Y'1 Lot Size: .Z-{ct quare Feet(circle units) <br /> Legal Description: OG1.1 � ,qj [ %o n. <br /> Age of wastewater treatment system LI [ (years) Is there a service contract for system components? NO, <br /> Date the septic tank was last pumped 7--%% t% (please attach receipt if available) <br /> Number of people occupying dwelling 7.j If unoccupied,for how long has it been vacant? VA <br /> Was this section completed by the evaluator because owner or agent was unavail ? <br /> The above information is true and to the best of my knowledge. <br /> 7.5 tat <br /> Date(MM/DD/YYYY) *gnature 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 /> ❑ 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: -6 - 1 ' (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 /> Nosk <br /> Date(MM/DD/YYYY) Signature of Quail:10,Quail: eptic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />