Laserfiche WebLink
a5- 0c:osy3 `? <br /> State of Oregon Department of Environmental Quality <br /> °` Annual Operation and Maintenance <br /> wrib <br /> DEQ Report Form <br /> General Information (CompleteALL information)( 2 <br /> Property Owner S V011'r�.C. CO A Phone: 5Dq - to-1 3\\ <br /> Site Address: 331\S 2_A \ Wye f Do '' "t Parcel#: <br /> City ` oNts County: p\k eA.C1I, <br /> • <br /> Permit#: 21 - O 5 2OTh Start up date If 1st year In use: <br /> System Model#: C System Serial#: <br /> Report Year: ��� `f Date of Service Performed: \tile\ 125 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> rq® ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> yJ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> El I 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 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. 1 <br /> *Maintenance Provider Name <br /> (please p print):i V Qacici �9 Jbhe3 <br /> "Certification#: OA ` U r) 'Certification Expiration: I '^"22) <br /> ('This fine only can be filled out and photocopied.) <br /> Original Signature: ,(/ L g/111-- Date: IN 244 <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 Operation and Maintenance Report Form Rev.612022 <br />