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r•, Oregon Department of Environmental Quality • Previous two years of maintenance records are vailable ❑Yes No If you answered"No,"please explain below: • Previous two years of maintenance records ar attached to this form ❑Yes No If you answered"No,"please explain below: • Additional Comments: 8. Please attach a copy of the following items to this form. Contact the DEQ, or the local Health Department to locate these items. •VAhe septic system permit(s)to this form,if available •✓✓Jhe as-built drawing(s)to this form,if available • The Certificate of Satisfactory Completion to this form,if available • Additional Comments: o,-4;/ 47e ) c foo /-$ -1-0 -be 4 p'vA_- ,Shap b N- - d-o tit _L,adh f P' 1 e j,. 'rev is #1oe6-S rat I a c-Z� A c,o/.et,- 6_ ex.s -;.!, s y S*C 9. Provide a Site Plan • 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 not ailable. • Please provide a sketc s of the complete system on page 8 of this form if the original"as- in t" drawing is nojor representative of the existing system. • Tithe original as-.uilt"drawing is available for copy, and the original appears to be accurate and representative of the existing system,write"see attached as-built"on page 8 of this form, redrawing the system is unnecessary. • Additional Comments: 10. Disclaimer: This evaluation report describes the septic system as it exists on the date of evaluation and to the extent that components and operation of the system are reasonably observable.DEQ recognizes that this evaluation report does not provide assurance or any warranty that the system will operate properly in the future. 11. Ihereby certify,by my signature,that the above information and the plot plan on the next page of this form are accurate and true to the best of my knowledge. 1St; Date Signature of Qualified Septic System Evaluator Page 7 of 8