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State of Oregon 9-l�l)")5C bt- J�./JQ l <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 (fir: 5 co c.._ Phone#: <br /> Site Address: a a l7 Skc- -6,, ea- or Parcel#: <br /> city 1-0 f to e-( county: M o.r i O in. <br /> Permit#: S S S - O LI S 3 ‘ Startup date if 1st year in use: <br /> System Model#: /tA r F r O • s- System Serial#: 9.1a.ao <br /> Report Year a 0 a S <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy) <br /> Yes No <br /> ® 0 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): LI Sr F4c.w,e-C- (ZG cL.cr&Son <br /> *Certification#: R.M % 00 `Certification Expiration: i a - is- 3S <br /> ('This line only can be tilled out and photocopied.) <br /> Original Signature: iOttE <br /> Date: t o- 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 />