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State of Oregon <br /> I'1 - 0�83"13.1AM <br /> Department of Environmental Quality <br /> Water Quality Division <br /> Onsite Program <br /> DEQ <br /> Annual Operation and Maintenance Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Joke t^ So✓ . Phone#: <br /> Site Address: a w - �GC'GSC��" QA or Parcel#: <br /> City: a e.,Ccr re-NO et County: AA ex 0 V\ <br /> Permtt#: O S - O 1.3 cl 7 Start up date if l st year in use: <br /> System Model#: AiC -o System Serial#: RTU LOSLK(r. <br /> Report Year: 1 O 3 C. <br /> Onsite wastewater treatment system status: (Do not prefili and photocopy) <br /> Yes No <br /> ® ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> © ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> ❑ © Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ ® Sewage backup into plumbing fixtures? <br /> If yes,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): ✓,l sc*kc. Rcu c.c'- F.6 GLcr atbor` <br /> *Certification#: t oo 'Certification Expiration: l a - IP,- 2 S <br /> (*This line only can be filled out and photocopied.) <br /> Original Signature: Date: l a- S-a S- <br /> Note: Maintenance providers 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 340-071-0130(24). <br />