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a5-bto39a- U-Y <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenanc <br /> DEQ Report Form <br /> General information (Complete ALL Information) <br /> Property Owner: Alexander Kravats Phone: 03- 77-5 <br /> Site Address: 1760 Scones Ferry Rd Ne Parcel#: <br /> City, Woodburn OR 97071 County: Marion <br /> Permit#: 555-22-004608-PRMT Start up date if 1st year in use: <br /> System Model#: AX-157883 System Serial#: RTU1485;3 <br /> Report Year: 2025 Date of Service Performed: # —,— <br /> Email Address:Of icetThaosnw.com <br /> Onsite wastewater treatment system status: (Do not preffll and photocopy checkbo. es) <br /> Yes No <br /> [ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> [rr11 El Is the system operating in accordance with the agent-approved design specifications? <br /> N . ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ Discharge of sewage to the ground surface? <br /> ❑ jj Discharge of sewage to drain tiles or surface waters? <br /> ❑ Egt• 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' 's <br /> report Is grounds for revocation of my certification and/or civil penalties. <br /> 'Maintenance Provider Name I =- _ , Li- I I- , ,-_1 s G.II- -__r • <br /> 'Certification#: R Certification Expiration: 04/24/27 <br /> ('This line only can b• lied out and photocep'• <br /> Original SIgnatu :: Date: - / -'� _ <br /> Note:Mainten-•-. • • dens 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 u..n <br /> request by the agency per OAR 340-071-0130(24). <br /> DEOA rc Cp,t r: .e...:_ xz y R :- Rtv.si2:•i2 <br />