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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 0 Permit Records 0 Measured❑Stamped on Tank❑Other • Dosing tank material • Dosing tank appears to be watertight and in good condition DYes ❑No • Dosing tank lid is intact DYes ❑No • Electrical components are sealed and watertight DYes ❑No • Pump/siphon is functional DYes ❑No • Type of Pump ❑Demand dose ❑Time dose • Pump control mechanism is functional(floats,pressure transducer)❑Yes ❑No • There is a high water alarm DYes ❑No • The high water alarm(audible and visual)is working DYes ❑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 DYes ['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?DYes ❑No ISee 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): Tank only inspection-client did not authorize • 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): ❑dropbox Ohydrosplitter❑equal distribution box ❑ Intact ❑Damaged ❑N/A • Absorption distribution unit(s)are free of debris or solids DYes ❑No❑N/A Page 4 of 8