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cm- 0to5ietp Utz\? <br /> -ti State of Oregon Department of Environmental Quality <br /> ra Annual Operation and Maintenance <br /> Report Form <br /> DEQ p <br /> General Information((Complete ALL Information)a c,. O. <br /> Property Owner: 9l- tl,\\'\,c��s�J UV_Cy Phone: a1;' U, <br /> Site Address: 3 _I rYXMG' u' Parcel#:City: lian5 County: 'MAUn4(-' <br /> Permit#: 7 , c1O`J)--`?17- Start up date If 1st year In use: <br /> System Model it: System Serial#: F <br /> Report Year 2o2S Oate of Service Performed: It ))0t S <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yea No <br /> R ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> c ❑ )s 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 /> ❑ SitIs the system failing? <br /> ❑ ca Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage la drain tiles or surface waters? <br /> ❑ 0 Sewage backup Into plumbing fixtures? <br /> If you answered "Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> t 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 <br /> U ` <br /> Name� (please print): <br /> 'Certification#: 1LY� '2kjJ ) *Certification Expiration: <br /> (*This line only can be filled out and photocopied.) <br /> ` <br /> Original Signature: L24I�A Date: II I/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 /> DEO Annual Ocesatlon and Maintenance Report Farm Rev.6/4021 <br />