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a5-oo\eACE:1 Z/ R <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: EAST SALEM 7TH DAY ADVENTIST CHURCH Phone: (503) 854-3496 <br /> Site Address: 5575 FRUITLAND RD NE Parcel#: T7S R2W S21CC TL3300 <br /> City: County: <br /> county: MARION <br /> Permit#: 555-23-005626 Start up date if 1st year in use: 07/19/2024 <br /> System Model#: AX2O 3-POD System Serial#: <br /> Report Year 2025 Date of Service Performed: 1 1/04/2025 <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IN Is the system failing? <br /> ❑ In Discharge of sewage to the ground surface? <br /> ❑ 1t Discharge of sewage to drain tiles or surface waters? <br /> ❑ i.I 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): Tim York- Septic Technologies <br /> 'Certification#: M592 'Certification Expiration: 03/26/26 <br /> ("This line only can be filled out and photocopied.) <br /> Original Signature: t Date: 12/31/2025 <br /> Note: Maintenance p iders 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 /> 5.2U2? <br />