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Form 1-2 Operational Checklist: System evaluation (SE

)
(This form is used for identification of the system design flow and to gather the operational checklists needed for conducting an O&M service visit.)

A. Client Contact n!ormation
Name of owner: Site address/County: Date of last service: System ref. #:

". System #ocumentation (See Form . System !escription (S!) for complete documentation)
Design flow: Gal per day

C. Operational Checklists (from Form . System !escription (S!) Section ")
Form $.1 Site Assessment on File. Yes No

%anks an& a&vance& treatment component operational checklists (Chapters '( ) an& *): ump: Demand!Dosed system: "ero#ic treatment unit: ump: $imer!Dosed system: %olding tan&: Septic/$ras(/ rocessing )tan&*: ump tan&)s*: -edia filter: Constructed wetland: 'agoon: Disinfection unit +C(lorine: Disinfection unit +,ltraviolet lig(t: Disinfection unit +./one:

Final treatment an& &ispersal component operational checklists (Chapter +): Gravity distri#ution: Drip distri#ution system: 0vapotranspiration #ed: -ound system: 1ottomless sand filter: 'ow!pressure drainfield: Spray distri#ution system: Disc(arging systems outfall: 1ottomless peat filter:

#. System Evaluation
2. 4. .3- service provided on: Date: $ime: .#servation and assessment of t(e site )on lot and in neig(#or(ood* a. 0valuate presence of odor wit(in 25 ft of perimeter of system: None -ild Strong C(emical Sour i* Source of odor6 if present: #. "ny surfacing or #rea&outs. c. "ny construction6 utility wor&6 or c(anges in drainage patterns. d. "re all components present and not modified. e. "re all lids at grade or on risers present and secure. f. $raffic on onsite wastewater system.

Yes 777 No7777 Yes 777 No7777 Yes 777 No7777 Yes 777 No7777 Yes 777 No7777

#: 8.System ref. Site status at conclusion of .esult: )gal* ! 'ast time: )gal* / 77777777777 gallons per day )gal* : .verall system condition: "ccepta#le . . @. >. Service notification.esult: 77777 gal days : 77777777777G D DD: $D: eople ump tan& control meter readings )indicate form used*: Disc(arge line meter 0stimate #ased on num#er of occupants: <.service visit: Berify t(at controls are set on t(e appropriate mode. Comments: C.pdates reAuired on Form 1. 0stimated system flow: 9ndicate met(od used for estimate: %ouse water meter reading: $(is time: .evisit all components to verify lids are secure. .naccepta#le -aintenance needed -aintenance performed -itigation reAuired Company name: "greement period from: to .1 System #escription: ?. Gat(er all tools for removal from t(e site. Complete operational c(ec&lists for final treatment and dispersal components )C(apter @*. Berify t(at no sewage is on t(e ground surface. =. Complete operational c(ec&lists for pretreatment components6 pumps6 pump tan&s and controls )C(apters =6 > and ?*. ower is on to all components.3. .

service visit. 9t does not guarantee t(at it will continue to function satisfactorily.$(is report indicates t(e condition of t(e a#ove onsite wastewater treatment system at t(e time of t(e .3. Signature of service provider: Date: .