Laserfiche WebLink
State of Oregon Department of Environmental Quality _'1 oot 17-D /n <br /> : „x:0 Annual Operation and Maintenance /YCX <br /> -,� .ram <br /> DEQ Report Form <br /> General Information(Complete ALL information) <br /> Property Owner Rob Wilcox Phone: 503-949-2733 <br /> Site Address, 6491 Guava Ct NE Parcel#: <br /> Salem <br /> City: Count': Marion <br /> Permit Sea: Start up dale it 1st year in use: 8/2023 <br /> System Model#: AS500L System Serial A070096 <br /> Repod Year: 2025 Date of Service Pe formed: 11/3/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not preftll and photocopy checkboxes) <br /> Yes No <br /> f[nn} ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> El ❑ 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 felling? <br /> ❑ m Discharge of sewage to the ground surface? <br /> ❑ fit Discharge of sewage to drain tiles or surface waters? <br /> ❑ 111, Sewage backup into plumbing fixtures? <br /> If you answered'Yes'on the last four questions.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): Austin Arts <br /> •Certification#: RM250 •Cerlificanon Expiration: 03/30/2027 <br /> (This pre only an be filed out and photo ) <br /> Original Signature: Date: <br /> 11�3/ ei <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 />