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r-' c. State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> Report Form <br /> DEQ <br /> ) oJvrn4.� tI1312b <br /> General Information (Complete ALL information) <br /> Property Owner: Go)' 6ruotPc.v( Phone: <br /> Site Address: !(G [.c�t S+ 6 Parcel#: I05 F-G(Gno c la <br /> City: D/ktr* County: / 4i-rrlcI L <br /> Permit#: S45- a0331? Start up date if 1st year in use: 4-e22.-o2$- <br /> System Model#: AX c*' OGi25 (37 System Serial#: 5 2m9vrr. S ZBt^C23 57G2k <br /> Report Year: aoac Date of Service Performed: II-aC-StS- <br /> Email Address: % offQ orsowt sac,-. oo^"^ <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> • ❑ Was maintenance perfomred as required by septic system rules and the manufacturer? <br /> ® ❑ Is the system operating in accordance with the agentapproved design specifications? <br /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® : 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: ✓/r- <br /> 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): iti. kcwhlwr <br /> 'Certification#. Es/ ISO 'certification Expiration: 4.-16-e210 <br /> ('This line only can be filled out and photocopied.) <br /> Original Signature: // Date: la 4 <br /> Note: Maintenance provide ust 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 /> DLO Annual Operation and Maintenance Report Form Rev 6t2C22 <br />