Laserfiche WebLink
State of Oregon Or'-Wp535-Ir3kg <br /> Department of Environmental Quality <br /> Water Quality Division <br /> Onsite Program <br /> DEQ <br /> Annual Operation and Maintenance Report Form <br /> General Information (Complete ALL information) <br /> Property Owner. -` r Phone#: <br /> Site Address: - LiV uil 6'-F �C or Parcel#: <br /> City: AJvti ,,s tlP County: /'AQF it O V\ <br /> Permit#: S5-5 1_6 - coa 3S Start up date if 1st year in use: <br /> System Model It: M C F T O . Jr System Serial#: O po an <br /> Report Year: aO 3 S <br /> Onsite wastewater treatment system status: (Do not prefili and photocopy) <br /> Yes No <br /> ® 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> © 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 /> ❑ ® 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): Ct Sc* C. Rohs..e'- ar M.on <br /> 'Certification#: R M too 'Certification Expiration: t a - \S- a <br /> ('This line only can be filled out end photocopied.) <br /> Original Signature: Date: t o- S-a S <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 />