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Oregon Department of Environmental Quality • Dosing tank capacity (gallons) • Tank volume determined by: Check all that apply,add comments below as needed El Permit Records❑Measured❑Stamped on Tank El Other • Dosing tank material • Dosing tank appears to be watertight and in good condition ['Yes ❑No • Dosing tank lid is intact ['Yes ❑No • Electrical components are sealed and watertight ['Yes ['No • Pump/siphon is functional ['Yes ['No • Type of Pump ❑Demand dose ❑Time dose • Pump control mechanism is functional(floats,pressure transducer)['Yes ['No • There is a high water alarm❑Yes ❑No • The high water alarm(audible and visual)is working ['Yes ❑No ❑Not Applicable • Type of screen • Screen is clean and free of debris DYes ❑No-Screen cleaned for this evaluation❑Yes ❑No • Scum/sludge present in Dosing tank ['Yes ❑No • Scum layer (inches) Sludge layer (inches) • Additional Comments: 5. Soil absorption system The soil absorption system is a set of trenches that receives effluent from the septic tank and filters the effluent before it enters the groundwater. • The septic system has a soil absorption system®Yes ['No ❑Unknown • Was the soil absorption system part of the evaluation?®Yes ❑No ❑See note below If the soil absorption system was not evaluated,please explain below(for example unable to locate,client did not authorize this part of the evaluation): • Absorption distribution [lEqual ❑Serial ['Pressure ['Equal via pressure • Absorption lines construction material: Gravel and pipe El Chamber El Tile El Polystyrene foam and pipe ❑Other • Absorption distribution unit(s): Ddropbox❑hydrosplitter l]equal distribution box Intact El Damaged VI N/A • Absorption distribution unit(s)are free of debris or solids IIYes ❑No❑N/A Page 4 of 8