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a'{-ouol b\-=N�` ) <br /> State of Oregon Department of Environment&Quality <br /> Annual Operation and Maintenance <br /> Report Form <br /> DEQ p <br /> General Information (Complete ALL information) �-r� /��] (� c <br /> Property Owner. Chr)S Q8 -hii/m&thh�er n Phone: CJV3-0/qi - "'62(0O <br /> Site Address: C Livl5 By "e Li I k Rd NT Parcel#' <br /> city: )v'Ora OR- criovl a county: Marion <br /> Permit* 655-t F �n <br /> 3 - �aqq Start up date if 1st year in use- <br /> System Model#: 2k)( 15 )a. System Serial#: R 1 O <br /> Report Year: 2024 Date of Service Performed: . •. . <br /> Email Address: Office(d aoSnW.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkbo ) <br /> Yes No <br /> KI ❑ Was maintenance performed as required by septic system rules and the manufacWrer? <br /> I ❑ 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 /> ▪ E4 Is the system failing? <br /> ❑ 14 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-Mat this-report Is complete and accurate to the best of my knowledge. I understand that falsification of thi <br /> report is grounds for revocation of my certification and/or civil penalties. <br /> "Maintenance Provider Name(please .• Matthew Landry Arne ir,_ar Sites <br /> tedification#: RM 17 on Expiration: 04124l27 <br /> (-This line only can bell + out and photocopied <br /> Original Signatur.. bate: •-�- <br /> Note:Maintenance provi - must mainta' -ccurate records of their maintenance contracts,customers, <br /> performance data,and timelines for renewing the contracts. These records must be available for inspection upor <br /> request by the agency per OAR 340-071-0130(24). <br /> Rev_6.2G22 <br />