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State of Oregon Department of Environmental Quality 1—OIDC:671A <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) 2 CLC <br /> Property owner h <br /> David & Cameron Buck BYtcSQ- R ` € 3 ac8a aaS <br /> 9544 & 9570 Broadacres Rd. NE <br /> Site Address: Parcel* <br /> City Hubbard county. Marion <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: DF60 System Serial#: 4669 <br /> Report Year: 2025 Date of Service Performed: 6/30/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill 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 /> ® 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 6n Is the system failing? <br /> ❑ I Discharge of sewage to the ground surface? <br /> O ,,t..(I. Discharge of sewage to drain tiles or surface waters? <br /> ❑ It 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 pent): Austin Arts <br /> 'Certification if: RM250 'Certification Expiration: 03/30/2027 <br /> ('This line only can be filled out and pho ) I / <br /> Original Signature: �..ci Date: iz( /'7/z <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 />