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• Oregon Department of Environmental Quality s :Previous two years of maintenance records are available DYes ONo If you.answered"Noi"-Plase explain below: ▪ Previous two y-ears of maintenance records are attached to this form DYes ONo . • If-you answered'No;please explain below: • Additional cOlnineniS: 8, Please attack a co0 of:the folfo-Wing items to this form.Contact the DEQ.or tite local Health Department to locate these items, * The septic system.permit(S)to this form,if available • The as-built drawing(S)to this form,if available O The Certificate of Satisfactory Completion to this form,if available •• Additional Comments: 9. Provides Site Plan o Please provide a sketch of the complete system(show only system components that were evaluated)on page 8 of this form,if a copy of the original"as-built drawing is nor available. 0 Please provide a sketch of the complete system on page a of this form if the original"as-built drawing is not accurate or representative of the existing system. the-original drawing-is available-for Copy,and the original appears to be accurate_and representatiVe of the existing system,write c'see attached as-built"on page 8 of this form, redrawing the systan is unnecessary. it Additional Commentst This evaluation report describes the septic system as it exists on the date of evaluation and to the ezt-tetit that components and operation of the system are reasonably obserVa.bie,DbQ recOe:nizes that this evaluation report does nut provide assurance or any wan-anty Marine system will operate properly in the future. 11. I hereby certify,by my signature,that the above information and the plot plan on the next page of this farm are accurate and true to the best of my know'ed . C) ?c3Z Date igna re of Qualiti Septic System luator Page 7 of 8