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Oregon Department of Environmental Quality • Previous two years of maintenance records are available OYesNo If you answered"No,"please explain below: • Previous two years of maintenance records are attached to this form Dyes .KNo If you answered"No,"please explain below: • Additional Com ents: • 8. Please attach a c or of the following items to this form.Contact the DEQ,or the local Health Department to loc:te these items. • The septic system permit(s)to this form, if available • The as-built drawl' g(s)to this form, if available • The Certificate of atisfactoiy Completion to this form, if available • Additional Comm-nts: 9. Provide a Site PI • Please provide a s etch of the complete system(show only system components that were evaluated)on pag; 8 of this form, if a copy of the original"as-built"drawing is not available. • Please provide a s etch of the complete system on page 8 of this form if the original"as-built" drawing is not ace'rate or.representative of the existing system. • • If the original "as-$wilt"drawing is available for copy,and the original appears to be accurate and representative oft e existing system,write"see attached as-built"on page 8 of this form, redrawing the systr m is unnecessary. • Additional Comm,nts: 10. Disclaimer: This evaluation re sort describes the septic system as it exists on the date of evaluation and to the extent that compo -nts 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 fut re. 11. I hereby certify,by my signature,that the above information and the plot plan on the next page of this form are accur:to and true to the best of my owledge. Z 0 4197 "i24 Date Signature of Qualified Septic System Evaluator Page 7 of 8 i