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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 j _Yes No * Electrical components are sealed and watertight Yes No * Pump/siphon is functional Yes No * Type of Pump J Demand dose Time dose • Pumpcontrol 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 r Yes No I I Not Applicable * Type of screen * Screen is clean and free of debris Yes Vo * 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 x Yes No Unknown * Was the soil absorption system part of the evaluation? x 1Yes , 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 Serial Pressure Equal via pressure * Absorption lines construction material: I I Gravel and pipe [ X I Chamber Tile Polystyrene foam and pipe Other * Absorption distribution unit(s): x dropbox hydrosplitter __Jequal distribution box X Intact Damaged N/A * Absorption distribution unit(s)are free of debris or solids I _x;Yes No N/A Page 4 of 8