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o <br /> 4 1-60 <br /> ocr 3 / ?ops <br /> Existing System Evaluation Report for Or1lt�i.w Cpr <br /> Wastewater Systems v a iNsiz) CoN <br /> DEQ State of Oregon Department of Environmental Quality <br /> 9abor 0.11W1 <br /> Ettpianensi Onsite Program <br /> awilennts East Seventh Ave, Suite 100 <br /> Query <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 visit <br /> http://www.oregon.gov/deq/Residential/Pages/Septic-Smart.asox. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): cj-jry u', QI./nlaaU 4s_ Telephone: (56_195)7 5)7/ Y <br /> Site Address: 13570 W2`[.ay..` City: Zip Code: <br /> County: M an ra.. Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system A/71 (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): Spars <br /> Certification: <br /> IM Installer 0 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: R2 Cjf - <br /> Business name &,fl e r /FA�X,(, j,1.ry Email <br /> Business address PD YOX .r!r (L fJoh on Phone (Sod Pk?-113, <br /> Date of Evaluation: /O-/,%i i (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 /> -)-et <br /> Date(MM/DD/YY YY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />