Laserfiche WebLink
Zto- 000257- ire <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> Report Form <br /> � <br /> DEQ ao - ,, (vitas <br /> PT il+IS TIME, <br /> General Information (Complete ALL information) <br /> 7Gvt o' fCatt. Ktmi- G <br /> Property Owner: `/ Y Phone: .>G 3— ��i -.2326 <br /> Site Address: /4g4Q S*"r"y p^ A ig Parcel#: 07 )F06 Poo7Zt) <br /> City: St laic« County: / -rrh4 <br /> Permit#: 4555- o24-6eR-41G Start up date if 1st year in use: lO-!'Y-�f <br /> System Model#: AX Z6 gT TS/ System Serial#: kr cl SS. / <br /> Report Year. O�s Date of Service Perfomhed: 10- - ZC <br /> Email Address: _iegtA-CV 0rcjC CP J -. CCU^ <br /> Onsite wastewater treatment system status: (Do not prefiil and photocopy checkboxes) <br /> Yes No <br /> - 0 - ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> ® ❑ 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 /> ❑ At; Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ [N 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: N)/.¢ <br /> !certify that this report is complete and accurate to the best of my knowledge. I understand that falsification of this <br /> report is grounds for revocation of my certification and/or civil penalties. <br /> `Maintenance Provider Name(please print): �1~ sag fica4s <br /> 'Certification fk 1`h 1'90 *Certification Expiration: 5- 16- 26 <br /> (?his line only can be filled out and photo spied. <br /> Original Signature: Date: /7-gr-ic <br /> Note: Maintenance provi 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 agency per OAR 340-071-0130(24). <br /> DEG Annual Ooeaetion and Maintenance Report Form Rev E,2O24 <br />