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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. Permit Records Measured Stamped on Tank Other * Dosing tank material * Dosing tank appears to be watertight and in good condition Yes No * Dosing tank lid is intact Yes No * Electrical components are sealed and watertight Yes No * Pump/siphon is functional Yes No * Type of Pump Demand dose Time dose * Pump control mechanism is functional (floats,pressure transducer) Yes No * There is a high water alarm Yes No * The high water alarm(audible and visual)is working Yes No Not Applicable * Type of screen * Screen is clean and free of debris Yes No * Screen cleaned for this evaluation Yes No * Scum/sludge present in Dosing tank Yes No * 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 x Yes No Unknown * Was the soil absorption system part of the evaluation? X Yes No 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): * Absorption distribution x Equal Serial Pressure Equal via pressure * Absorption lines construction material: x Gravel and pipe Chamber X Tile Polystyrene foam and pipe Other * Absorption distribution unit(s): dropbox hydrosplitter x equal distribution box Intact x Damaged N/A * Absorption distribution unit(s)are free of debris or solids x Yes No N/A Page 4 of 8