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ci <br /> State of Oregon Department of Environmental Quality a 3- b W o ` '+-i•+Q? <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> • <br /> General Information (Complete ALL information) <br /> Holy Family Academy (503) 235-1777 <br /> Property Owner: Phone: <br /> 10697 Howel Prairie Rd NE 062W01 01400 <br /> Site Address: Parcel#: <br /> Salem Marion <br /> City. County: <br /> 555-23-006554-PRMT <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: System Serial#: <br /> 2025 8/19/2025 <br /> Report Year: Date of Service Performed: <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑x ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> ❑x ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> ❑x ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ In Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ ❑� Discharge of sewage to drain tiles or surface waters? <br /> ❑ E 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): Daniel Gavotto - Septic Technologies <br /> `Certification#: RM 169 `Certification Expiration: 8/29/26 <br /> (*This line only can b d ou nd photocopi <br /> to 12/31/2025 <br /> Original Signature: Date: <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 /> DEG Amaai Doe'a 'on ann Mamieante Report ro'r Rev 621Z9 <br />