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,� Oregon.Department of Enyironmentai Quality 0 Previous two years of maintenance records are available Dyes QNo Ifyou answered"No,"please explain below: o Previous two years of maintenance records are attached to this form Dyes ❑No If you answered"No,"please explain below: Additional Comments: S. Please.at# a copy(If the following items to this form. Contact the DEQ or the local Health. Depart;nezt to locate these items. e The septic s3.,stern.permit(s)to this form,if available • The as-built drawing(s)to this toam,if available • The Certificate of Satisfactory Completion to this form,if available ® Additional Comments: 9. Provide a Site Plan G Please provide a sketch of the complete system(show only system components that were evaluated)on page 8 of this form,if a copy of the original'as-built"drawing is not available. • Please provide a:sketch of the complete system on page 8 of this form if the original "as-built" drawing is not accurate or representative of the existing system: • Iftheoriginal "as-b€ai1t".dra wngis available-for co re Presentative copy,and the original appears to be accurate and p of the existing system,.write`:see attached as-built'on page 8 of this form, redrawing the system is unnecessary: • Additional Comments: 10. Disclaimer: This evaluation report describes.the'septic system as it exists on the date of evaluation and to the extent that components and operation of the system are reasonably observable. DEQ recognizes that this evaluation-report does not provide assurance or any warranty that the system will operate properly in.the future. 11. I hereby certify, by my signature,that the above information and the plot plan oh the next page of this form are accurate and true to the best of my knowled Date • iana re ofQualifra f Septic System --aluator Pag '7 of 8