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P Oregon Department of Environmental Quality • Previous two years of maintenance records are.available [Yes No t.fyoti•answered"No,"please explain below: • Previous two years of:maintenance records are attached to this form ['Yes .ENo If you.answered"No,"please explain below: • • Additional Comments: }'tease attach a copy of the following items to tins form.Contact the OW,or the local Health fiepartinent to locate these items. • The septic system,perrriit(s)to this form, if available • The as-b.uilt drawing(s)to this form,if available • The Certificate of Satisfactory Completion to this form,if available • Additional Comments: 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 available. • Please provide a sketch of the complete system on page 8 of this form if the original"as-built" drawing'is not accurate or representative of the existing system. • If the original.:"as-built"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 systen 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:conip000cnt§and ope. at on of the system are reasonably observable LUEQ recognizes that this evaluation report does not proVide assurance or any warranty that the system will operate properly in the future. l l. I hereby 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 knowled . Date igrtature of Qualified Septic System aluator Page 7 of 8