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State of oregon 015_61:B451 5&1- <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: - Rc.c S e-Ca Phone#: <br /> Site Address: G O Coe 'bTG., . K as S U or Parcel it <br /> City: T C.r,.er County: Masi 0 i/A <br /> Pemiit#: SSS- - 00 r-t .O7,4 Start up date if 1st year in use: M0.�f <br /> System Model#: L P D System Serial*: L. (o 0 = N �i <br /> Report Year. a O a S r, <br /> Onsite wastewater treatment system status: (Do not prefill 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 /> ® 0 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 thee 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): L1 Sc-ktc kkc.,.V.es- (Z_t cLsc &Son <br /> `Certification#: kk-M lOO 'Certification Expiration: t 2 - lR.- 2$- <br /> (*This line only can be filled out and photocopied.) <br /> Original Signature: Date: t 3- 5 -O <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 />