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11 - bo1 oya=-17JQ <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner MARION COUNTY PUBLIC WORKS Phone: (503) 576-0595 <br /> Site Address: 5155 SILVERTON RD NE Parcel#: T7 R2W S8D TL300 <br /> City: SALEM county: MARION <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: RECIRCULATING GRAVEL FILTER System Serial#: <br /> Report Year: 2025 Date of Service Performed: 11/13/2025 <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefiil and photocopy checkboxes) <br /> Yes No <br /> Q ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> 0 0 Is the system operating in accordance with the agent-approved design specifications? <br /> E ❑ 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 /> ❑ a 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 rent)• <br /> /A Richard Taylor - Septic Technologies <br /> 'Certification#: RM79 // ! `CertifcationExpiration: 03/27/27 <br /> ('This line only can be filled out pho ed:(Y/ 7 <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers must mainta' ccurate 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 />