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State of Oregon Department of Environmental Quality a✓C)O\b_l \—Dva ` <br /> • Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> GK Machine (503) 235-1777 <br /> Property Owner: Phone: <br /> 20495 Belleville Rd NE 041 W18 00201 <br /> Site Address: Parcel it: <br /> Donald County: Marion <br /> City: <br /> 555-23-009204-PRMT 10/24/2024 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: System Serial#: <br /> 2025 12/5Y2025 <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 /> ❑ Q Is the system failing? <br /> ❑ • Discharge of sewage to the ground surface? <br /> ❑ ❑� Discharge of sewage to drain tiles or surface waters? <br /> ❑ ❑� 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: 8r29r26 <br /> (*This line only can be out d photocopie <br /> 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 /> 0_�a,.. zc-e Iv a-e Reo•c�.�-. Ray . -, <br />