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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 ❑ Measured ❑ Stamped on Tank❑ 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 ❑Yes 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? EYes 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 ❑✓Serial ['Pressure ['Equal via pressure • Absorption lines construction material: (1 Gravel and pipe ❑ Chamber ❑ Tile ❑ Polystyrene foam and pipe ['Other • Absorption distribution unit(s): ❑✓dropbox ❑hydrosplitter['equal distribution box n Intact ❑ Damaged ❑N/A • Absorption distribution unit(s)are free of debris or solids ❑✓Yes ❑No ❑N/A Page 4 of 8