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all-cOCti38: &Y <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> John Bratton <br /> Property Owner: Phone: <br /> 4561 Hazelgreen Rd. <br /> Site Address: Parcel#: <br /> Salem y Marion <br /> City: Count <br /> Permit it Start up date if 1st year in use: 9/2023 <br /> System Model#: AS500L System serial#: A070544 <br /> Report Year: 2025 Date of Service Performed: 10/24/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 81 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> i0 Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> O I . Discharge of sewage to the ground surface? <br /> O IS 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#: RM250 'Certification Expiration: 03/30/2027 <br /> (*This line only can be filled out and pho e 4 / <br /> Original Signature: Date: VOA <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 /> pFr_Annual,rerxion IV t<'nnanc Form <br /> Rrv..m7U92 <br />