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��-hr» 0k3 INQ <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: LIVELY STATION Phone: (312) 719-8889 <br /> Site Address: 3635 RIVER RD S Parcel#: T8 R3W S6DB TL500 <br /> City: JEFFERSON county: MARION <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 07/21/2025 <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not preffll and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ 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 Is the system failing? <br /> ❑ is Discharge of sewage to the ground surface? <br /> ❑ IN 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?rint): Richard Taylor - Septic Technologies <br /> 'Certification#: RM79 / 'Certification Expiration: 03/27/27 <br /> ('This line only can be filled out�h//'oto ied.) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers mu aintain 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 />