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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 0 Other • Dosing tank material • Dosing tank appears to be watertight and in good condition ❑Yes ❑No • Dosing tank lid is intact [Nes ❑No • Electrical components are sealed and watertight ❑Yes ❑No • Pump/siphon is functional Oyes ❑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 Oyes ❑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.,__,r.( • The septic system has a soil absorption system Il Yes ❑No ❑Unknown • Was the soil absorption system part of the evaluation? 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 ❑Equal Zserial ❑Pressure ❑Equal via pressure • Absorption lines construction material: ❑Gravel and pipe %Chamber ❑Tile ❑Polystyrene foam and pipe ['Other • Absorption distribution unit(s):Vdropbox❑hydrosplitter Dermal distribution box ❑intact Damaged ❑N/A • Absorption distribution unit(s)are free of debris or solids Oyes ❑No❑N/A Page 4 of 8