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Oregon Department of Environmental Quality <br /> a Previous two years ofxnai uce records are available []Yes tj o <br /> If you ana ore "No,"please explain below: <br /> a Previous two years ofmaidenance.records are attached to this form Dyes [DNo <br /> If you aaswerel,"No,"please explain below: <br /> • Additional Comments: <br /> 8. Pleaseattach'a copy oftbe following items to this form.Contact the DEQ,or the local Health <br /> Department to locate tbese items. <br /> • The septic system pe it(s)to this form,if available <br /> s The as-built 3rawing(s).tothis form,if availab <br /> +� The Certificate of Sry Compleblonto this form,if available <br /> • Additional Co its; <br /> 9. Provide a Site Plan <br /> • Please provide a sketch Rite complete system(show only System components that: <br /> evaluated)wiper:B ofthrs foam,if a copy of the original,` s 'drawing is notavaiable. <br /> • Please provide 8aketch ofthe complete system mina 8 of this form lithe original"as-built" <br /> drawing is not accurate or representative ofthe existingst s. <br /> •: If the original"as-built"drawing is available for copy,and the original appears to be accurate and <br /> representative of the-fig;system,write"see attached as-built"on page S of this form, <br /> redrawing the system is unnecessary. <br /> • Additional Comments: <br /> 10. Disclaimer: <br /> This evaluation report'describes the septic system as it exists on the date of evaluation aid to the <br /> extent that components and operation of the system are reasonably observable.DEQ recognizes <br /> that this evaluation report does not provider or any wanantytbat the system will operate <br /> properly in the future. ' <br /> 1 i.I.hereby certify,by my striatum that the above information «•'the.plot-plan .8.. a':.next page of <br /> this form are accurate and true to the best of my knowledge:' <br /> Date Signature of Qualified Sep 4`c • 'r3 .. <br /> Page 7 of 8 <br />