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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. Permit Records I Measured ;Stamped on Tank I Other * Dosing tank material * Dosing tank appears to be watertight and in good condition Yes No * Dosing tank lid is intact % j Yes I No * Electrical components are sealed and watertight E [Yes [. No • Pump/siphon is functional , — Yes ( No * Type of Pump 3 Demand dose L Time dose * Pump control mechanism is functional (floats,pressure transducer) `Yes No - 1 r * There is a high water alarm % J Yes ._._.__ No * The high water alarm(audible and visual)is working i_ Yes __mm`No I Not Applicable * Type of screen * Screen is clean and free of debris rmr Yes i o * Screen cleaned for this evaluation I 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 ! x..._I Yes I I No j Unknown * Was the soil absorption system part of the evaluation? ).LI 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 Equal ' x_ ;__..... p ___ q i x Serial , Pressure ;Equal via pressure * Absorption lines construction material: Gravel and pipe x Chamber €____,_ Tile j Polystyrene foam and pipe Other * Absorption distribution unit(s): x ;dropbox jhydrosplitter €equal distribution box l Intact _j Damaged N/A * Absorption distribution unit(s)are free of debris or solids xYes No N/A Page 4 of 8