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I"1 -rrr>Lci5--m)Q <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> David & Cameron Buck 6 iusaac' 'Zak 54a yo3 4a>S <br /> Property Owner: Phone: <br /> 9514 & 9524 Broadacres Rd. NE Parcel it: <br /> Site Address: <br /> City: Hubbard County: Marion <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: DF60 System Serial#: 4666 <br /> Report Year 2025 Date of Service Performed: 6/30/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> E ❑ 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 /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ iA Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ Discharge of sewage to drain tiles or surface waters? <br /> ❑ ti,j 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#: <br /> RM250 'Certification Expiration: 03/30/2027 <br /> ('This line only can be filled out and photo ) <br /> Original Signature: ?. "-" Date: <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 />