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, <br /> . . <br /> . e . <br /> ' . <br /> State of Oregon <br /> Department of Environmental Quality <br /> Water Quality Division <br /> DEQ - Onsite Program , <br /> State of Oregon <br /> pepertment of • Annual Operation and Maintenance. Report Form <br /> awhoimentA <br /> . • Quality . <br /> - - • <br /> General.information <br /> Property Owner: °'')l.)50k.vN \f`P.: .\ Phone#: b' '. --.209S- kirrAC <br /> Site Address: 1...5‘cb \-%cii3ki Ntt VI etAi SX'4 City: r-3C4,._ VV\ . <br /> County: WA.OVieri Or\ Permit#: Startup Date: <br /> System Model#: System Serial#: • <br /> Service Report Year: '2-011 . • . <br /> . • <br /> . . . <br /> . . • <br /> ' " • Onsite wastewater treatment System statUs: <br /> Yes No ' <br /> , • <br /> • ., . <br /> NC• E] Was maintenance performed as required by septic system rules(OAR 340-071)and • <br /> the manufacturer? - • • • <br /> • <br /> • <br /> $ El Is the system operating in accordance with the agent-approved design specifications? <br /> Z. ED Is the sistem currently under a service contract with a certified maintenance provider? <br /> Is the system failing? <br /> . . , <br /> ' . <br /> n <br /> El NI Discharge of sewage to the ground surface • .. . <br /> ..., - • ED TEL Discharge of sewage to drain tiles orSurface waters <br /> 41- • . <br /> CD IX Sewage backup into plumbing fixtur,1 <br /> ED ED If yes,was a repair permit obtained?If pot,explain: <br /> •! i ' <br /> • <br /> . , . <br /> ' . <br /> ..• <br /> •'. I. <br /> • <br /> , Ild: • , <br /> I certify that this report is complete and accurate to th hest of my knowledge.I understand that falsification of <br /> this report is grounds for revocation of my certificatio:24nd/or civil penalties, <br /> I . 1 t <br /> Maintenance Provider Name(please print): V35(.1... ei)Y\c — II\Or\ \I\J ft. -Ttr-WA 6. <br /> . , <br /> Certification#:SSO\--1D- Certification Expiration/late: <br /> t 11, 1 <br /> 0 \CI <br /> 1 . <br /> II Ei 2 n <br /> - Signature: — 1 1 r Date: *-I-) - <br /> „. , • - <br /> , ( <br /> Note:Maintenance providers must maintain accurate le prds of their maintenance contracts,cust9mers, • - <br /> performance data,and timelines for renewing the confracjts. These records milk be available for inspection upon <br /> • ,request by the agent per OAR 340-071-0130(24). . i: , • <br /> , . <br /> - (- <br /> .. . , • <br /> - i• <br /> a , , 1 • <br /> .,-- <br /> , ' i" ; •• <br /> . . <br />