Laserfiche WebLink
t°1--Ob3-590-DQE. <br /> State of Oregon <br /> Department of Environmental Quality <br /> Water Quality Division <br /> DEQ <br /> Onsite Program <br /> State ofOrego <br /> f Annual Operation and Maintenance Report Form <br /> EnvironQuality a <br /> General Information <br /> Property Owner: Ferguson Waterworks Phone#: 503-799-1672 <br /> Site Address: 3650 Kashmir Way SECity: Salem, OR 97317 <br /> County: Marion Permit#: Startup Date: Unknown <br /> System Model#: Sand Filter System Serial#: N/A <br /> Service Report Year: 2018 <br /> Onsite wastewater treatment system status: <br /> Yes No <br /> EZ] fl Was maintenance performed as required by septic system rules(OAR 340-071)and <br /> the manufacturer? <br /> 1E = Is the system operating in accordance with the agent-approved design specifications? <br />-- ---- - --- QX n -Is the system currently under a service contract with a certified maintenance provider-?- -Is the system failing? <br /> Yes No <br /> M Discharge of sewage to the ground surface <br /> I-1 Discharge of sewage to drain tiles or surface waters <br /> I XI Sewage backup into plumbing fixtures <br /> I-1 n If yes,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 <br /> this report is grounds for revocation of my certification and/or civil penalties. <br /> Maintenance Provider Name(please print): Ken Deneault <br /> Certification#: RM-93 Certification Expiration Date: 04/04/19 <br /> Signature: #E Date: 3/19/19 <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 agent per OAR 340-071-0345(14). <br /> Annual Operation and Maintenance Report Form <br /> Rev. 11/2011 11-WQ-055 <br />