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Oregon Department of Environmental Quality • Dosing tank capacity 1000 (gallons) • Tank volume determined by: Check all that apply, add comments below as needed ❑ Permit Records® Measured❑ Stamped on Tank❑ Other • Dosing tank material concrete • 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 vault&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 1 (inches) Sludge layer2 (inches) • Additional Comments: This system is a septic and dosing tank combination. 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 ['Equal ®Serial ❑Pressure ❑Equal via pressure • Absorption lines construction material: Gravel and pipe ❑ Chamber ❑ Tile El Polystyrene foam and pipe ElOther • Absorption distribution unit(s): ®dropbox❑hydrosplitter❑equal distribution box ® Intact ❑ Damaged El N/A • Absorption distribution unit(s)are free of debris or solids ®Yes ❑No ❑N/A Page 4 of 8