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State of Oregon Department of Environmental Duality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Daniel & Teri Petre Phone: 503-1190-9390 <br /> 6295 Lake Labish Rd. NE <br /> Site Address: Parcel#: <br /> Salem Marion <br /> City: County: <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: DF50 System Serial#: 25582 <br /> Report Year: 2025 Date of Service Performed. 10/18/2025 <br /> Email Address: vanpek-re-aaa 5mAtl_• COvYI <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ��[] ❑ was maintenance performed as required by septic system rules and the manufacturer'? <br /> Ley ❑ 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 /> ❑ ® 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#: RM250 *Certification Expiration: 03/30/2027 <br /> (*This line only can be tilled out and photoco ' .) / <br /> Original Signature: Date: Vt]' t6 <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 /> f)60 Annual 0 pcaaon and\laintc 1anm Ru part For- Rev.60022 <br />