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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 ZYes ['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 ❑ Polystyrene foam and pipe ❑Other • Absorption distribution unit(s): Edropbox❑hydrosplitter❑equal distribution box [a Intact ❑Damaged ❑N/A • Absorption distribution unit(s)are free of debris or solids VeYes ['No El N/A Page 4 of 8