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• <br /> as- obo5H2 3 ° <br /> ✓"'1'L State of Oregon Department of Environmental Quality <br /> Tl:_ .z� A Annual Operation and Maintenance <br /> DEQ <br /> Report Form <br /> General Information (C A omplete ALL Information) `- p Z <br /> Property Owner: , `AOC eb t O VS \ QA0r( r\ Phone: IJ0J-V11- U� v <br /> Site Address: \ O <br /> i.` SYb to ?NA.?NA. Parcel#: <br /> City: C1a)`/�JW y�,� County: <br /> Permit#: \ - 0 O' -i t Start up date if 1st year in use: <br /> System Model#: System Serial#: <br /> Report Year: 201---c 7 Date of Service Performed: I2}29 JL5 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> `a1 ❑ 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 /> 1 ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 14 is the system failing? <br /> ❑ tzli Discharge of sewage to the ground surface? <br /> ❑ rff Discharge of sewage to drain tiles or surface waters? <br /> ❑ Ix�.. 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):p' l 1 QSS\c G 3ohe 7 <br /> 'Certification#: 1)Yv-\ V ""Certification Expiration: I1/0'//3 <br /> ('This line only can be filled out and photocopied.) <br /> t � <br /> Original Signature: yr/-st M J ) — ' Date: ( I / - `e <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 /> DEO Annual Operalion and Maintenance Report Form Rev.6/2022 <br />