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Oregon Department of Environmental Quality <br /> SCG eLt (u4,-04 crum c,,ty 1 ,:: Se p4; - 1 I-5- ZoZo <br /> • The septic tank material is: <br /> [ oncrete <br /> Steel <br /> Plastic <br /> • Fiberglass • <br /> n Other(explain) <br /> f Unknown• <br /> a Ts the septic tank accessible? es ❑No <br /> • Septic tank volume in gallons <br /> • Tank volume determined by: Check all that apply,add comments below as needed <br /> ❑Permit Records❑Measured ❑ Stamped on Tank❑Other <br /> • Septic tank risers are at ground level EYes ❑No <br /> • Tank appears to be free from defects, Ieaking and signs of deterioration 'Mies ❑No <br /> If you answered"No,"please describe the condition of the septic tank below. For example, <br /> evidence of gas corrosion, cracks, leaks, etc. <br /> • Septic tank lid(s) is intact ❑Yes ❑No <br /> • Septic tank baffles are intact:Inlet ❑Yes ❑No Outlet ❑Yes ENO <br /> • Baffle material-Inlet❑Plastic ❑Concrete [Metal Outlet 'Plastic =;Concrete (Metal <br /> Effluent filter is present ❑Yes ❑No <br /> • Effluent filter is free of debris ❑Yes ❑No ❑Not Applicable <br /> • Liquid Level in tank relative to invert of outlet ❑At ❑Above ❑Below <br /> If above or below invert outlet, please explain: <br /> • Scum layer (inches) Sludge layer (inches) <br /> • Scum and Sludge layer more than 35%of the total tank volume ❑Yes ❑No <br /> Indicate where sludge measured from: ❑inlet ❑Middle Outlet <br /> • Additional Comments: <br /> 4. Dosing tank/Pump Basin <br /> Dosing tanks use a pump to send effluent to a treatment unit or a soil absorption field. <br /> • The septic system has a dosing tank ❑Yes ❑No <br /> (If"No,"skip the rest of section 4) <br /> • At the time of this evaluation the power was on to test the pump(s): ❑Yes ❑No <br /> Page 3 of 8 <br />