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State of Oregon Department of Environmental Quality t -co 05-tMl <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner JEFFERSON BAPTIST CHURCH Phone: (541 ) 327-2939 <br /> 15002i 99_ 19 R3W S136C 11900 <br /> Site Address: Parcel Parcel#: <br /> City: JEFFERSON 1WT county: MARION <br /> Permit#: 555-18-000885 Start up date if 1st year in use: <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 08/08/2025 <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ 0 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 /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ In Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ in Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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(pleas: •rin Richard Taylor - Septic Technologies <br /> `Certification#: RM79 'Certification Expiration: 03/27/27 <br /> ('This line only can be filled out- • phdo ied.) <br /> Original Signature: , -/ Date: 12/31/2025 <br /> Note: Maintenance providers must intain 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 />