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• <br /> Oregon Department of Environmental Quality <br /> • Previous two years of maintenance records are available ❑Yes ❑No <br /> If you answered"No,"please explain below: <br /> • <br /> c Previous two years of maintenance records are attached to this form :Wes DNo, <br /> If you answered"No,"please explain below: _ <br /> Additional Comments: . <br /> 8. Please attach a copy of the following items to this form.Contact the DEQ, or the local Health <br /> Department to locate these items. <br /> a. Please attach a copy of the original septic system permit to this form,if available <br /> b. Please attach a copy of the original as-built drawing to this form,if available <br /> c. Please attach a copy of the Certificate of Satisfactory Completion to this form,if available <br /> • Additional Comments: <br /> • <br /> 9. Provide a Plot Plan <br /> o Please provide a sketch of the complete system on page 7 of this form,if a copy of the original <br /> "as-built"drawing is not available. <br /> • Please provide a sketch of the complete system onthe "as-built" <br /> page. 7 of this form if original <br /> drawing is not accurate or representative of the existing system. <br /> 6 If the original"as-built"drawing is available for copy,and the original is accurate and <br /> representative of the existing system,write"same as as-built"on page 8 of this form,and do not <br /> redraw the system. <br /> ® Additional Comments: <br /> • <br /> 10. Disclaimer: <br /> This evaluation report describes the on-site system as it exists on the date of inspection and to the <br /> extent that components and operation of the system are reasonably observable.DEQ recognizes <br /> that this evaluation report does not-provide assurance or any warranty that the system will operate <br /> .properly in the future. " <br /> • <br /> 11. I hereby certify,by my signature,that the above information and the plot plan on the next page of <br /> this form are accurate and true to the best'drily knowledge. <br /> �_ d 1 <br /> Date Signature of Qualified Septic System Inspector <br /> Site Address: - <br /> Page 7 <br />