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{ <br /> • <br /> • <br /> 6,-;;;-_-1, Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> DEQ State of Oregon Department of Environmental QualityCeporarl <br /> Onsite Program <br /> 165 East Seventh Ave,Suite 100 <br /> 0.44 <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/Septio-Smartaspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Ryan Minch Telephone: 503-502-6063 <br /> Site Address: 11788 Towers Rd SE City_ Stayton Zip Code:97383 <br /> County: Marion Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: <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? 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 0 Environmental Health Specialist <br /> ✓ 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: },6/1-11 7,, g (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 I 1-0155. <br /> Date I 'D/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of B Updated 12/29/2016 <br />