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• <br /> .,�*), State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> ra <br /> Report Form <br /> DEQ p <br /> General Information (`C1omplle�te ALL1 iinformatiio-nn))C c� <br /> Property Owner: (7v1� 1r\ V1V,-1C.11h1VJ' Phone: 341- V5\- 0 I 0 C <br /> Site Address: 11I "t't- 11CATrKt Y\ Parcel#: '11 ,. <br /> City: 5t(C�, ' t"�n C12J County: VWA1�1 <br /> Permit#: 11 - 0 V1L ` J Start up date if 1st year In use: <br /> System Model#: -1 System Serial II: <br /> Report Year: 2�<� y�Date of Service Performed: t s-I^q-'1 I Jq <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> IFI ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> p ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> p ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ' Is the system faling? <br /> ❑ Ig Discharge of sewage to the ground surface? <br /> ❑ S Discharge of sewage to drain tiles or surface waters? <br /> ❑ p 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 <br /> I codify 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 11 "�(pleaseeprlint): 3 tSS\ (ex 30�� 44 <br /> `Certification#: �W\ /�\o ) 'Certification Expiration: i' 0 _ ) <br /> ('This line only can be filled out and prh�otooccopi�ed.) <br /> Original Signature: Ai'✓l�ri(Nr bklie� Date: ` I I PI' <br /> Note: Maintenance providers must maintain accurate records of their maintenance contracts,customers, <br /> performance data,and timelines(or renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual Operation and Maintenance Report Form Rev.6I2022 <br />