Laserfiche WebLink
aa-Olt555-Q9 <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> Report Form <br /> DEQ p <br /> General Information (Complete ALL information) <br /> Don Suklis <br /> Property Owner: Phone: <br /> 1748 Ankeny Hill Rd. <br /> Site Address: Parcel#: <br /> City: Jefferson County: Marion <br /> Permit#: Start up date if I st year in use: <br /> System Model#: AS500L System Serial#: A067571 <br /> Re port Year: 2025 10/24/2025 <br /> P Date of Service Performed: <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 /> © ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> ® t ] Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ im t Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ ®. Discharge of sewage to drain tiles or surface waters? <br /> ❑ S 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): Austin Arts <br /> "Certification#: RM250 'Certification Expiration: 03/30/2027 <br /> (*This line only can be plied out and photocopie <br /> Original Signature: _. .lr-�9 `/(72.' <br /> Date: <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 /> D6o Annual Oper rion and Maifinnarre keDod Farm Rev.312022 <br />