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_- -i State of Oregon Department of Environmental Quality a(.p b34yDT .)ng <br /> :' Annual Operation and Maintenance <br /> Report Form <br /> DEQ Re p . <br /> General Information (`Complete ALL Information) p'/ U p' <br /> Property Owner, ('hr45LI4tt SY1 �{-fGVA/ Phone: l o�J Fi o 99/O <br /> Site Address:{^ �'2' A(rporb iQ Parcel#: <br /> City: Aildr4Jyta County: Ma.rt.041. <br /> Pernit#: 555-Z/1N -oa 99lV-Pawl- Start up date if 1st year inuse: CMS/7 If <br /> -system-Model#;.. - A K 2 a E 1 ) 51770 system Serial* IC k l s'oC2 7_...._. _ <br /> Report Year. �"% Date of Service Performed: )211 e/2 5— <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> E ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> ,}I{� ❑ Is the system operating in accordance with the agent-approved design specifications? ) <br /> V❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ s the system failing? <br /> ❑ FrOlscharge of sewage to the ground surface? n <br /> ,._,j <br /> ElI iT Discharge of sewage to drain tiles or surface waters? r �1' J `'VP <br /> ❑ ErSewage 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 /> dl r�'Maintenance Provider Name(please print): rft Q. 5 <br /> ( <br /> *Certification#: II` y1 2-76 lv/�` <br /> (`This line only can be filled out photacop <br /> ta//6/25" <br /> Note:Maintenance providers must maintain accurate records of their maintenance contracts,customers, <br /> performance data,and timelines for leirowing the contracts, These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEQ Annual Operation and Maintenance Report Form Rev.6/2022 <br />