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EC-WE <br /> Existing System Evaluation Report for Onsit n <br /> Wastewater Systems MAY 0 3 2019 <br /> DEQ <br /> State of Oregon Department of Environmental Quality �1 MARION COUNTY <br /> do Onsite Pr ram 3JII_.DING INSPECTION <br /> • <br /> Emtorrenvd 165 East Seventh Ave,Suite 100 <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/PageslSeptic-S mart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Ted Koellman Telephone; 503-931-7498 <br /> Site Address: 14535 Spenner Rd SE City: Stayton Zip Code: 97383 <br /> County: Marion Lot Size: 3 acres Acres/Square Feet(circle units) <br /> Legal Description: 091W02A 00200 <br /> Age of wastewater treatment system (years) Is there a service contract for system components? <br /> Date the septic tank was last pumped (please attach receipt if available) <br /> Number of people occupying dwelling 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 /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Richard Westerlund--NAWT 124931TC <br /> Certification: <br /> ❑ Installer 0 Professional Engineer <br /> ❑ Maintenance Provider ❑ Environmental Health Specialist <br /> 0 National Association of Wastewater Technicians 0 Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 33013 <br /> Business name Ace Septic and Excavating Email office©ace-septic.com <br /> Business address PO Box 9177, Brooks,OR 97305 Phone 503-393-1033 <br /> Date of Evaluation: 05,10( /ZL L.e4 (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 OAR 341 171-0155. <br /> `_ <br /> � / <br /> fill &� (.�'� � ��' 1., 2r. Z 31"11— <br /> Date ft /DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />