Fillable Printable 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).