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State of Oregon Department of Environmental Quality O 3-0lo0-l`L T N l it <br /> t Annual Operation and Maintenance <br /> Report Form <br /> DEQ p <br /> General Information (Complete ALL information) <br /> Property Owner: 1\n1 CU N 045h Phone: 5010- 522- kg.\ <br /> Site Address: 255 DeVaA\ \fri q t. J Parcel#: ��11,, <br /> City: �t'tYCh'� County: MOO(1Oft <br /> Permit#: Ti1 � `)OO5 CAy Start up date If 1st year in use: <br /> System Model#: System Serial#: <br /> Report Year: Z 02 E Date of Service Performed: 12I^_0 1-2-5 <br /> J <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkhoxes) <br /> Yes No <br /> (l ❑ 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 /> ❑ 1Z! 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 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):f� ) 1 Cc" Utf-t 1 1 '� I"� yp-.1 <br /> 'Certification#: sk -Luc)) 'Certification Expiration: �I I r '�G <br /> ('This line only can be filled 41(ous�t and photocopied.) <br /> Original Signature: t44 e4 Y ertm__. Date: \I) Rio <br /> Note:Maintenance providers must maintain accurate records of their maintenance contracts, customers, <br /> performance data,and timelines far 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 Operallon and Malnlenance Report Form Rev.62022 <br />