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State of Oregon Department of Environmental Quality 11 - O 1 V� u- "L"e <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: BUENA CREST SCHOOL Phone: (503) 581-1152 <br /> Site Add ess: 8485 RIVER RD NE Parcel it: T6 R3W S24A TL1700 <br /> Cm. KEIZER county: MARION <br /> #: 07-06438 <br /> Permit <br /> Start up date if 1st year in use: <br /> System Model#: GRAVEL FILTER System Serial#: <br /> Report Year 2025 <br /> Date of Service Performed: 08/04/2025 <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 0 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q 0 Is the system operating in accordance with the agent-approved design specifications? <br /> p 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IN Is the system failing? <br /> ❑ It Discharge of sewage to the ground surface? <br /> 0 ® 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 int): Richard Taylor- Septic Technologies <br /> *Certification it: RM79 /7,7 .' *Certification Expiration: 03/27/27 <br /> ('This line only can be filled/oy�d o pie ' <br /> Original Signature: il""c Date: 12/31/2025 <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 /> GF., ,ry tr ca',I <br /> zo�z <br />