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State of Oregon I 1 -DD$3-1DD V <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: Z77 e,r1!.�.. Phone#: <br /> Site Address: t a g Oct Girt .. A ccrS or Parcel#: <br /> City: —34.cCes SOn County: /`^US i O\ <br /> Permit#: 0 7- O 3 74.a Startup date if let year in use: <br /> System Model#: A 1C System Serial#: 'it'll) to 6 Z q l- <br /> Report Year a O 2 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 fifes 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): G t Sc - &bon <br /> `Certification#: it..M tOO 'Certification Expiration: to - - as <br /> ('This line only can be filled out and photocopied.) <br /> Original Signature: Date: l 3- S-2 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 />