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Oregon Department of Environmental Quality • Previous two years of maintenance records are available DYes DNo If you answered"no,"please explain © Previous two years of maintenance records are attached to this form ClYes CINo If you answered`No,"please explain below: • O Additional Conmients: • • 8. Please attach a copy of the following items to this form.Contact the DEQ,or the local Health Department to locate these items. a. Please attach a eopy of the original septic system permit to this form,if available b. Please attach a copy of the original as-built drawing to this form,if available c. Please attch a copy of the Certificate of Satisfactory Completion to this form,if available e Additional Comments: 9. Itovide a Plot Plan O Please provide a.sketch of the complete system on page 7 of this form,if a copy of the original "as-builr"&awing is not available. • Please provide a.sketch of the complete system on page 7 of this form if the original"as-built" drawing is not accurate or representative of the existing system. O If the original"as-built"drawlg is available for copy,and the original is accurate and representative of the esting system,write"same as as-built"on page 8 of this form,and do not redraw the system. O Additional Comments: 10. Disclaimer: This evaluation report describes the on-site system as it exists on the date of inspection and to the extent that components and oPer4on 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 tare to the best of my knowledge. •Date Sig.nature of Qualified Sep1ie System-Inspector . . Site Address: Page?