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Oregon Department of Environmental Quality <br /> Aio 1 uics ?O1 "c 7 ket 4: Cc- 1-Izic', kar <br /> • The septic tank material is: <br /> [1( Concrete <br /> L Steel <br /> Plastic <br /> E] Fiberglass <br /> Other(explain) <br /> n Unknown <br /> ® Is the septic tank accessible? pies ❑No <br /> • Septic tank volume in gallons 09t)- <br /> • Tank volume determined by: Check all that apply, add comments below as needed <br /> fp Permit Records n Measured❑ Stamped on Tank❑Other <br /> • Septic tank risers are at ground level Yes [j]No <br /> • Tank appears to be free from defects,leaking and signs of deterioration ]Yes [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 [XYes No <br /> • Septic tank baffles are intact:Inlet pYes ❑No Outlet ['Yes ['No <br /> • Baffle material-Inlet 1QPIastic ❑Concrete ff1Metal Outlet rPlastic ❑Concrete rMetal <br /> Effluent filter is present ❑Yes 1 No <br /> • Effluent filter is free of debris [lYes ❑No Not Applicable <br /> Liquid level in tank relative to invert of outlet ❑At DAbove ❑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 EINo <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 /> e 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 />