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State of Oregon Department of Environmental Quality a\-b i a55aa9 <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Mike & Becky Bend Phone: <br /> 12413 Dominic Rd. NE <br /> Site Address: Parcel#: <br /> City: Mt. Angel County: Marion <br /> Permit It. Start up date if 1st year in use: <br /> System Model#: AS500L System Serial#: A063892 <br /> Report Year: 2025 Date of Service Performed: 5/6/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 14 ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> g ❑ 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 /> ❑ tyl` Discharge of sewage to the ground surface? <br /> ❑ Discharge of sewage to drain tiles or surface waters? <br /> ❑ 1Z 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 ph to / <br /> Original Signature f�--sue — _ Date: '/ /2_c <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 /> DEO Annual Operation ned M irIte-once Hooa.l ro,m tic".5nm2 <br />