Laserfiche WebLink
State of Oregon Department of Environmental Quality P a-�,` `�\ 1� V istQ <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) La is skr a. E,ntoi pr i5t5 <br /> proms,Owner -�dibatttt Enterprises Phone: 503 — q Sa- 2.a30 <br /> 18213 Arbor Grove Rd. NE Parcel#: <br /> Site Address: <br /> City: Woodburn county: Marion <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AS500L System Serial#: A065951 <br /> Rspon Year. 2025 Date of Service Performed:5/7/2025 <br /> Emelt Address: <br /> Onslte wastewater treatment system status: (Do not ()refill and photocopy checkboxes) <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 /> Eta ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ itia Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ 1a Discharge of sewage to drain tiles or surface waters? <br /> ❑ 04 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 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): Austin Arts <br /> *Certification#: <br /> RM250 "Certification Expiration: 03/30/2027 <br /> ('This line only can be filled out and photo ) <br /> Original Signature: � Date: Z/r/2� <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 />