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as-oc61\3zNdN <br /> . ✓ h} State of Oregon Department of Environmental Quality <br /> r,-,#T,SIA Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information r \ <br /> (Complete� ALL information) ll � II � CC ^'7 <br /> Property Owner: v``S 'SQ6\(2- �L Phone: iv.F - 0- <br /> Site Address: 505t- 7 V\hn 'Or Parcel#: <br /> City: ('\pk*-05 County: N.a( itn <br /> permit#: Z\ - 0 O'JS J3 Start up date if 1st year In use; <br /> System Model#: System Serial#: <br /> Report Year: 2 OZ S Date of Service Performed: 1 L PA VC <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 1# ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Sir 0 Is the system operating In accordance with the agent-approved design specifications? <br /> 51, ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 7A Is the system failing? <br /> ❑ i' Discharge of sewage to the ground surface? - <br /> ❑ F2 Discharge of sewage to drain tiles or surface waters? <br /> ❑ I . 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): 3 1501 CAt���-� (� <br /> *Certification#: (`)1A 1A(b *Certification Expiration: 1 W <br /> 7,6 <br /> ('This tine only can be filled out and photocopied.) <br /> �ry{1p� 11 <br /> Original Signature: Stintia 2(1/" -'" Date: ' <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 /> CEO Annual Operation and Maintenance Report Form Rev.612022 <br />