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State of Oregon oa1a18Y <br /> Department of Environmental Quality <br /> p Water Quality Division <br /> Onsite Program <br /> F Yli i`1 <br /> DEQ <br /> Annual Operation and Maintenance Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: t c0.a Av.ra er SO vi Phone#: <br /> Site Address: l"iS S TI T:n R:LXc R A or Parcel#: <br /> City: 3cc-cabon County: / A-cS Lon <br /> Permit#: SSS - as -00 BG3S - 9RNtT start up date iflst year in use: <br /> System Model#: D F System Serial#: N /q <br /> Report Year: aG�S <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy) <br /> Yes No <br /> ® ❑ 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 /> ❑ © Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ ® Sewage backup into plumbing fixtures? <br /> 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 this <br /> report is grounds far revocation of my certification and/or civil penalties. <br /> "Maintenance Provider Name(please print): L:saf+e_ Rr v-.cr - Ro C, c r&Sen <br /> `Certification#: AM t o G "Certification Expiration: (1• tb-gyp, <br /> (This line only can be filled out and photocopied.) <br /> Original Signature: Date: t -lt- -S <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 agency per OAR 340-071-0130(24). <br />