Laserfiche WebLink
23 - a-too62 MJQ' <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Rosalba Diaz Ruiz 503-930-4267 <br /> Property Owner: Phone: <br /> 9533 Golf Club Rd. SE <br /> Site Address: Parcel#: <br /> Di y <br /> Aumsville Count Marion <br /> Y: <br /> Permit#: Start up date if 1st year in use: <br /> AS600NR NR002440UV <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 11/3/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> T ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> igl 0 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 /> ❑ VI Is the system failing? <br /> ❑ a Discharge of sewage to the ground surface? <br /> ❑ 5a. Discharge of sewage to drain tiles or surface waters? <br /> ❑ IR 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 *Certification Expiration: 03/30/2027 <br /> ('This line only can be filled out and photo • .)Original Signature: Date: 1/6(/ <br /> 2-6 <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 /> DEt]Annual Oncnauan intavzaa.keno o1 Form <br />