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at\- Loay=oQt-? <br /> State of Oregon Department of Environmental Quality <br /> ' Annual Operation and Maintenance <br /> Report Form <br /> DEQ p <br /> General Information (Complete ALL information) QQOO,, tt ` <br /> Property Owner: Ybn `4-5 r\A\ Phone: b�)77 -%o- E�'bJ <br /> Site Address: l0O lbOt\\O V Parcel#:City: th))( ,\\ 'C County: `p <br /> NA( 1t)(N. <br /> Permit#: '2`- O� 4 V Start up date if 1st year in use: <br /> System Model#: System Serial#: <br /> Report Year: Date of Service Performed: <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I I D Was maintenance performed as required by septic system rules and the manufacturer? <br /> ▪ 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 /> ❑ Is the system falling? <br /> ❑ [ . Discharge of sewage to the ground surface? <br /> ❑ v- Discharge of sewage to drain tiles or surface waters? <br /> ❑ Y"p 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 his <br /> report is grounds for revocation of my certification and/or <br /> civil penalties. �\\ <br /> 'Maintenance Provider Name\� (please print): Jess)CCA UX3h QS <br /> *certification#: „k 2113 *Certification Expiration: CI "'-Vel <br /> ('This line only can be filled out and <br /> ��ph��ot Nocopied.)) // <br /> -0I'YVe "r zci D �ate: I) IZ <br /> Original Signature: /�ii <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 Operalion and Malnlenance Report Form Rev.612022 <br />