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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 D Permit Records D Measured D Stamped on Tank D Other • Dosing tank material • Dosing tank appears to be watertight and in good condition ['Yes DNo • Dosing tank lid is intact DYes ONo • Electrical components are sealed and watertight DYes ['No • Pump/siphon is functional DYes DNo • Type of Pump ['Demand dose ['Time dose • Pump control mechanism is functional(floats,pressure transducer)DYes ONo • There is a high water alarm DYes ONo • The high water alarm(audible and visual)is working DYes [No ❑Not Applicable • Type of screen • Screen is clean and free of debris DYes ONo-Screen cleaned for this evaluation[]Yes ONo • Scum/sludge present in Dosing tank ['Yes ONo • 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 Wes DNo DUnknown • Was the soil absorption system part of the evaluation?DYes NINo ['See 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): k'Se(a Leal Q® i.^S 4/1 cio • Absorption distribution VEqual ['Serial . ['Pressure ['Equal via pressure • Absorption lines construction material: Zi Gravel and pipe D Chamber D Tile D Polystyrene foam and pipe ['Other • Absorption distribution unit(s): Odropbox Ohydrosplitter[Z]equal distribution box. (E Intact D Damaged D N/A • Absorption distribution unit(s)are free of debris or solids . Yes ONo D N/A 1 . • Page 4 of 8