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2-4 - oo 4-10 - QV <br /> "Et, State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ ReReport Form <br /> p ca-n tts MC <br /> General Information (Complete ALL information) <br /> Property Owner S<.-<ti Vvt4S5Cr Phone: <br /> Site Address: 93b$ S<f.,ei. Emu c fit ..y Parcel fir :t Lv 11 n4 oIvo z <br /> City: Atry-4S,4414v r 4'7S2C County: f 'r/Mwh <br /> Permit#: 54ri— 2O - CG$56$ Start up date iflst year in use: N//r <br /> System Model#: AX O A) —0 L1 System Serial#: I -7 R D rSG - Z <br /> Report Year. 102 c Date of Service Performed: <br /> Email Address: _loci..@ otter, <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 1 ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> gj 0 Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ 14 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> ❑ gl Discharge of sewage to the ground surface? <br /> ❑ P4 Discharge of sewage to drain tiles or surface waters? <br /> ❑ Eu Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> -I certify,that this report is complete and accurate to the best of my knowledge. I understand that falsification of this <br /> report is grounds for revocation of my certification and/or civil penalties. <br /> `Maintenance Provider Name(please print): Lct kdcvtu,.. — (9vs. ,.. Siwr, r / nc,.-. ti <br /> 'Certification#: 1201. (So 'Certification Expiration' 5-lc ".24, <br /> ('This line only can be filled out and photocoppiiedd.)) <br /> Original Signature: / // Date: 1.'t- 7-4 . <br /> Note: Maintenance pro evM rs must maintain accurate records of their maintenance contracts,customers, <br /> performance data,and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0t30(24). <br /> DEG Annual Operafon and Maintenance Report Form Rao V2D22 <br />