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aD- b0b\1Qg <br /> r7•'t State of Oregon Department of Environmental Quality <br /> rht ; Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALLInformation) U (� Q cL <br /> Property Owner: �V\1'tt \t-\ ' Lt.1 p Phone: 1‘— -I�0.CJ' 1%�-p <br /> Site Address: 1V^Ck_` w\\\bU1 10%4A, CNA. Parcel#: , 1 <br /> City 1-6ri✓Qtrf h—1 0.1,, County: {�Q(Y3(N <br /> Permit tl: ` v'' v v 1D \ ' Start up date If 1st year In use: <br /> System Model#: System Serial#: <br /> Report Year: 20 `J Date of Service Performed: Q.I I bi ,rj <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 11 ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> )21. 0 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 /> ❑ 171. Is the system falling? <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/oo\r civil penalties. <br /> 'Maintenance Provider Name(please print): \1Q55‘ CC .)c) .S <br /> 'Certification#: OM 2l1)5 'Certification Expiration: <br /> 9 \-wLe) <br /> ('This line only can be filled out��anti�p��hootq4 ,toccopied.) I,, <br /> Original Signature: 4.v{'JV( -"� Date: 1 \ \ ) 2l0 <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.6/2022 <br />