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• <br /> Oregon Department of Environmental Quality <br /> C <br /> - . S e5Aex -1 . (-1..2 c <br /> e The septic tank material is: <br /> E. •Concrete <br /> 0 Steel <br /> Plastic <br /> El Fiberglass <br /> Other(explain) <br /> ❑ Unknown <br /> e Is the septic tank accessible? ❑`i'es DNo <br /> o Septic tank volume in gallons <br /> o Tank volume determined by:Check all that apply,add comments below as needed _z; <br /> ❑Permit Records❑Measured 0 Stamped on Tank❑Other • <br /> • Septic tank risers are at ground level D Yes ❑No • <br /> o Tank appears to be free from defects,leaking and signs of deterioration❑Yes DNo <br /> If you answered"No,"please describe the condition of the septic tank below.For example, <br /> evidence of gas corrosion,cracks,leaks,etc. <br /> o Septic tank lid(s)is intact Dyes ❑No <br /> • Septic tank baffles are intact:Inlet ❑Yes ❑No Outlet ❑Yes ❑No <br /> o Baffle material-Inlet j'lastic M£oncrete ❑Metal Outlet InPlastic ❑Concrete ❑Metal <br /> Effluent filter is present ❑Yes DNo <br /> o Effluent filter is free of debris ['Yes ❑No ['Not of Applicable <br /> o Liquid level in tank relative to invert of outlet ❑At ['Above [(Below <br /> ; <br /> If above or below invert outlet,please explain: _ - . _, - <br /> ® Scum layer (inches) Sludge layer (inches) <br /> 9 Scum and Sludge layer more than 35%of the total tank volume ❑Yes [No <br /> Indicate where sludge measured from:DInlet ['Middle ❑Outlet • <br /> o Additional Comments: • • <br /> 4. Dosing tank/Pump Basin • £ <br /> Dosing tanks use a pump to send effluent to a treatment unit or a soil absorption field. <br /> ® The septic system has a dosing tank ['Yes ONo <br /> (If"No,"skip the rest of section 4) <br /> e "At the time of this evaluation the power was onto test the pump(s): ❑Yes ❑No <br /> Page 3 of 8 <br />