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/9 & f <br /> Existing System Evaluation Report for Onsite <br /> Wastew: ter. Systems <br /> DEC/ <br /> t. : State of Oreg•n Department of Environmental Quality <br /> doe Onsite Progra <br /> E'6"" °' 165 East Sev:nth'Ave, Suite 100 <br /> Eugene, OR 9 401 <br /> Please answer the followin q questions completely. Do not leave any blank responses.Write unknown if <br /> unknown. Refer to Oregon dministrative Rule 340-071-0155 for more information, and please <br /> • <br /> visit:http://www.oregon.gov deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provi a ed Information: <br /> Property Owner(s)(Sellers): ¶A\ftp-. Qtatootik Telephone: So3—Ot''\—C1 1t <br /> 21kol Vj,\\t,r <br /> Site Address: � � City: Su k.,./W1 Zip Code; °C11007.— <br /> County: UCLA-D(p Lot Size: \ •k3 1 41;Square Feet(circle units) <br /> Legal Description: t) OM., 01.11OO <br /> Age of wastewater treatment 'i stemlt,, (years) Is there a service contract for system components? VO <br /> Date the septic tank was last p mped (please attach receipt if available) <br /> Number of people occupying wellin& If unoccupied,for how long has it been vacant? I W <br /> Was this section completed ' the evaluator because owner or agent was unavailable? k.i,Q,S <br /> The above information is tr e and to the best of my knowledge. <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing valuation(please print): Sv ' ' 17. , 3=Z'r. <br /> Certification: <br /> 0 Installer 0 Professional Engineer <br /> ❑ Maintenance Provider 0 Environmental Health Specialist <br /> 0 National Association of astewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: NA 13493ITC <br /> Business name Ace Septic-nd Excavating, Inc. Email office@ace-septic.com <br /> Business address PO Box 91 r.7, Brooks, OR 97305 Phone 503-3934033 <br /> Date of Evaluation: O4-t P i 6 t Zo L f (MM/DD/YYYY) <br /> 1 hereby certify,by my signat re,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the stat• of Oregon pursuant to OAR 34 -071-0155. <br /> 0 - w .' <br /> Date(MM/DD/YYYY) Signa a of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated-12/29/2016 <br />