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IS- obcb4°\• 1J& <br /> -'' State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenanc : <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property owner: Yvonne Petty Phone: 503-550 9373 <br /> Site Address: 255 Se. Plant Street Lane Parcel#: <br /> City: OR 97302 County: Marion Coun <br /> permit* 555-04-04582 Start up date if 1st year in use: <br /> System Model#: AX-105281 System Serial#: RTU104.77 <br /> Report Year. 2025 Date of Service Performed: 1/24/25 <br /> Email Address:Officelcaosnw.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkbo- es) <br /> Yes No <br /> ❑ Was maintenance performed as required by septic system rules and the manufacture(? <br /> a0 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 /> ❑ a, Discharge of sewage to drain tiles or surface waters? <br /> ❑ [ti- Sewage backup into plumbing fixtures? <br /> If you answered'Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> !tardy thatthia report Is complete and xneate to the best of my knowledge. I understand that falsification of tnis <br /> report is grounds for revocation of my certification and/or civil penalties. <br /> 'Maintenance Provider Name(Please Mt): tr._t r- erg American On Site <br /> 'Certification#: RM,Y72 / Certification Expiration: 04/24/27 <br /> ('This line only can b 'filled out and ph pied.) <br /> Otginal Signatu e: Date: <br /> Note: Maintenance viders must maintain accurate records of their maintenance contracts,customers, <br /> performance da ,and timelines for renewing the contracts. These records must be available for inspection u n <br /> request by the agency per OAR 340-07I-0130(24). <br /> DEQ _; ._ ._✓ R .Y.F:: 1 Ra, 5;2_22 <br />