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Oregon Department of Environmental Quality <br /> * Dosing tank capacity (gallons) <br /> * Tank volume determined by:Check all that apply,add comments below as needed. <br /> Permit Records Measured ` Stamped on Tank Other <br /> * Dosing tank material <br /> * Dosing tank appears to be watertight and in good condition Yes No <br /> * Dosing tank lid is intact I, YesI No <br /> * Electrical components are sealed and watertight Yes No <br /> * Pump/siphon is functional Yes No <br /> * Type of Pump "Demand dose 'Time dose <br /> * Pump control mechanism is functional(floats,pressure transducer) jYes No <br /> * There is a high water alarm Yes I No <br /> * The high water alarm(audible and visual)is working ' !Yes ! s No Not Applicable <br /> * Type of screen <br /> * Screen is clean and free of debris Yes !No <br /> * Screen cleaned for this evaluation Yes No <br /> * Scum/sludge present in Dosing tank I _'Yes i No <br /> * Scum layer (inches) Sludge layer (inches) <br /> * Additional Comments: <br /> 5. Soil absorption system <br /> The soil absorption system is a set of trenches that receives effluent from the septic tank and <br /> filters the effluent before it enters the groundwater. <br /> * The septic system has a soil absorption system x 'Yes i No Unknown <br /> * Was the soil absorption system part of the evaluation? x Yes No See note below <br /> If the soil absorption system was not evaluated,please explain below(for example unable-to locate,client did not <br /> authorize this part of the evaluation): <br /> * Absorption distribution Equal Serial ;Pressure ;Equal via pressure <br /> * Absorption lines construction material: <br /> x Gravel and pipe Chamber Tile . Polystyrene foam and pipe Other <br /> * Absorption distribution unit(s): x .dropbox _ hydrosplitter ! equal distribution box <br /> x Intact Damaged N/A <br /> * Absorption distribution unit(s)are free of debris or solids x:Yes No 'N/A <br /> Page 4 of 8 • <br />