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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 ❑Y"es ❑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 stem P 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 EYes ❑No ❑Unknown • Was the soil absorption system part of the evaluation?Pres ONo 111See note belo w 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 pqual ❑Serial [Pressure ['Equal via pressure • Absorption lines construction material: ;S'Gravel and pipe ❑Chamber ❑Tile ❑ Polystyrene foam and pipe ❑Other • Absorption distribution unit(s): ❑dropbox❑hydrosplitter Witqual distribution box p{Intact ❑Damaged ❑N/A • Absorption distribution unit(s)are free of debris or solids ['Yes [plNlo❑N/A / S L b 9/4,►vlbcp Purr Lis") --Z7:2r -r OL,e / y Ewa tt.� Page 4 of 8 l�10�ia�c,,� 74't y' Mil y