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21-0l2y32 (/JQL1 <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) pp Ord <br /> Property Owner: Joe Kuzmin Phone: SDI -99/ <br /> 4359 Sleepy Hollow Ln NE Parcel#. <br /> Site Address: <br /> Silverton Marion <br /> City: County: <br /> Permit#: Startup date if 1st year in use: <br /> #; AS500L A065453 System Model <br /> System Serial#: <br /> Report Year: 2025 5/6/2025 <br /> Date of Service Performed: <br /> Email Address: Toe A tzv r) 1486 V Ryvfw1 coy) <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 /> EA. ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> IA. ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® 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): Austin Arts <br /> 'Certification it: RM250 'Certification Expiration: 03/30/2027 <br /> ('This line only can be filled out and photo <br /> / <br /> Original Signature: �.-- Date: I `�7i( <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 /> oEoAnnualOperaAa and"in Rr -n r Renal Fein, <br /> He a,^an <br />