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Fillable Printable Maintenance Report Form - Oregon

Fillable Printable Maintenance Report Form - Oregon

Maintenance Report Form - Oregon

Maintenance Report Form - Oregon

State of Oregon
Department of Environmental Quality
Water Quality Division
Onsite Program
Annual Operation and Maintenance Report Form
General Information
Property Owner: Phone #:
Site Address: City:
County: Permit #: Startup Date:
System Model #: System Serial #:
Service Report Year:
Onsite wastewater treatment system status:
Yes No
Was maintenance performed as required by septic system rules (OAR 340-071) and
the manufacturer?
Is the system operating in accordance with the agent-approved design specifications?
Is the system currently under a service contract with a certified maintenance provider?
Is the system failing?
Yes No
Discharge of sewage to the ground surface
Discharge of sewage to drain tiles or surface waters
Sewage backup into plumbing fixtures
If yes, was a repair permit obtained? If not, explain:
I certify that this report is complete and accurate to the best of my knowledge. I understand that falsification of
this report is grounds for revocation of my certification and/or civil penalties.
Maintenance Provider Name (please print):
Certification #: Certification Expiration Date: ____________
Signature: Date:
Note: Maintenance providers must maintain accurate records of their maintenance contracts, customers,
performance data, and timelines for renewing the contracts. These records must be available for inspection upon
request by the agent per OAR 340-071-0130(24).
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