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.. State of Oregon 25- U� '^ ` <br /> r /- Department of Environmental Quality <br /> • Water Quality Division <br /> Onslte Program <br /> DEQ <br /> Annual Operation and Maintenance Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner: r.liS Phone#: <br /> Site Address: 3O F40 3 CWtc OI - JC'O OC or Parcel#: <br /> City: J e-Qrr San County: /M O\,f i. O VA <br /> Permit#: S S' P. 3 — 00 "lc O a Start up date if 1st year in use: <br /> System Model#: L. Q P System Serial#: N/A <br /> Report Year: D..0 3 S <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy) <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 /> ® ❑ 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 yes,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): C. SC.'kk c 1--\ --e s- lie cL.ar <br /> *Certification#: (A.M la `Certification Expiration: t 3 - lR•- 35— <br /> ('This line only can be filled out end photocopied.) <br /> Original Signature: Date: l 3- S- 2 5- <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 />