Laserfiche WebLink
State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> Report Form <br /> DEQ p <br /> General Information (Complete ALL information)Property Owner. Ub Ja\moo qr\ Phone: So3- el50- I e <br /> Site Address: 5 -13 Wt%CALM uooi Parcel#: <br /> city: I I � J county: �AC1fiJfl <br /> Permit#: 'k- Ovw'\1t 0% Start up date If 1st year In use: <br /> System Model#: System Serial#: <br /> Report Year: 2 02'5D Date of Service Performed: LI 7-q 125 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not profit] and photocopy checkboxes) <br /> Yes No <br /> ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> cEr ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> p ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ vt Is the system failing? <br /> ❑ r�bn Discharge of sewage to the ground surface? <br /> ❑ Discharge of sewage to drain tiles or surface waters? <br /> ❑ a 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 hest of my knowledge. 1 understand that falsification of this <br /> report is grounds for revocation of my certification and/or civil penalties. <br /> `Maintenance Provider Name(please print):Q Jess1 C'S 3o�) <br /> `Certification#: CAVIL 2(9 v `Certification Expiration: -`I i'5) <br /> ('This line only can be filled out artdddphhotocopied.) �5 <br /> Original Signature: ,.,4?LP e) .�f i�laiL— Date: I I <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 /> DEC Annual Dperallon and Maintenance Repod Fonn Rev.612022 <br />