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State of Oregon 025-0bO 566 D 1 1 <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: I. LS S C Phone#: <br /> Site Address: 17 .°-I S C....) GAl ( r<.n a or Parcel#: <br /> City: C..4Cr.CS County: N\O.S i ov\ <br /> Permit#: S S 5 - a l - O O R `1 S-S Start up date if 1st year in use: <br /> System Model#: J 9 0 System Serial#: A..i(n <br /> Report Year a 0 a s- <br /> Onsite wastewater treatment system status: (Do not ()refill 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): "Sc.4kc <br /> 'Certification#: RM too `Certification Expiration: I a - i$- 3$- <br /> ('This line only can be filled out and photocopied.) <br /> Original Signature: Date: t o- S-2 <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 />