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Oregon Department of Environmental Quality .. • Previous two years of maintenance records are available: QYes ONo If youanswered"No,"please;explain below: • Previous two years:of maintenanc• e records are attached to this'form ['Yea ONo If you answered"No,"please'explain below: • • Additional Comments::: g. Please'attach a copy of the following items to this form Contact the DEQ,or the local Health .Department to'locate these items.': • The septic:system permit(s)tt this form,if available • The as built drawuig(s)to this form,if available • The Certificate of Satisfactory Completion to this form,if available • Additional Comments:::: 9 Provide a SitePlan s 'stem(show system componentsthat'wer e • Please provides sketch of the complete y only evaluated)on page 8 of this form,if a copy of the original"as;built"drawing is .ot 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 system is unnecessary. :; • Additional Commentst 10. Disclaimer: This:evaluation report descrihes the septic system as it exists on the date of evaluation and to the extent that components 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 future 11. 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 knowledge:: .07731- 2.'60;2- Date Signature., Qualified Septic System Evaluator Page 7of8