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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 componentsare sealed and watertight Dyes ❑No • Pump/siphon is functional Dyes ❑No • Type of Pump ❑Demand dose ❑Time dose • Pump control mechanism is functional(floats,pressure transducer)Dyes [No • There is a high water alarm Dyes ❑No • The high water alarm,(audible and visual)is working Dyes ❑No ❑Not Applicable • Type of screen • Screen is clean and free of debris Dyes ❑No-Screen cleaned for this evaluation ❑Yes ❑No • Scum/sludge present in Dosing tank Dyes ❑No a 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 KYes ❑No ['Unknown • Was the soil absorption system part of the evaluation?Wes ❑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): a Absorption distribution NEqual ❑Serial ❑Pressure ❑Equal via pressure • Absorption lines construction material: ❑ Gravel and pipe ❑Chamber :Is Tile ❑Polystyrene foam and pipe ❑Other • Absorption distribution unit(s): ❑dropbox[ihydrosplitter gequal distribution box S Intact ❑Damaged ❑N/A • Absorption distribution unit(s)are free of debris or solids ❑Yes [No❑N/A Page 4 of 8