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4s- 11- 8 sty' <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenanc > <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner. Lee McCloud Phone: 971-239-9388 <br /> Site Address: 413 Bavarian Way Se Parcel It: <br /> City: Salem OR 97317 County Marion <br /> Permit#: Start Start up date if 1st year In use: <br /> System Model#: White Water System Serial#: <br /> Report Year. 2025 Date of Service Performed: -el <br /> Email Address: Offices aosnw.com <br /> Onsite wastewater treatment system status: (Do not preflll and photocopy checkb•) es) <br /> Yes No <br /> IA ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> ,Lr�/ El Is the system operating in accordance with the agent-approved design specifications? <br /> 12 ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ El/ Is the system falling? <br /> ❑ [2 Discharge of sewage to the ground surface? <br /> ❑ E(EDischarge of sewage to drain tiles or surface waters? <br /> / <br /> ❑ L 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 civil penalties. <br /> `Maintenance Provider Nam- :lease print): iu - r r- , „r,•s d u=i - r •r - <br /> *Certification#: RM 2 Aller- :piration: 04/24/27 <br /> (*This line only can be fill:. out and photocopl= <br /> Original Signature: Date: I .f_ <br /> Note:Maintenance p • ••-rs must main :in emu.- records of their maintenance contracts,customers, <br /> performance de, - d timelines for renews • . e contracts. These records must be available for inspection u.-n <br /> request by .•- agency per OAR 340-071 I 30(24). <br /> DEC}Arr --__ Vat cer.r F rt F�.a R@ti.EL� <br />