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n.0bo—tb8 ZM(Q/ <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> • <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Margaret Sakoff Phone: <br /> 3196 Cloverdale Dr. SE <br /> Site Address: Parcel#: <br /> city: Turner County: Marion <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: DF50 System Serial#: 25088 <br /> Report Year: 2025 Date of Service Performed: 8/14/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefitl and photocopy checkboxes) <br /> Yes No <br /> 14 a Was maintenance performed as required by septic system rules and the manufacturer'? <br /> ® ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> m ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ El Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ is Discharge of sewage to drain tiles or surface waters? <br /> ❑ 54 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 a .)Original Signature: Date: /0/ 4,4 <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 /> reo Amur operator and Mandenance Haar:ranP <br />