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a3-oeCDsS19TA.11) <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. HOLY TRINITY PRIVATE SCHOOL Phone: (503) 874-1557 <br /> Site Address: 9410 RAMBLER DR NE Parcel#: T6 R12 S13D TL200 <br /> City: SILVERTON county: MARION <br /> Permit#: 555-20-006681-PRMT-01 Start up date if 1st year in use: <br /> System Model#: AX 1 OO System Serial#: <br /> Report Year: 2025 Date of Service Performed: 08/04/2025 <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ 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 /> ❑ ® 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/g : Richard Taylor - Septic Technologies <br /> *Certification#: RM79 "Certification Expiration: 03/27/27 <br /> (*This line only can be filled out .•. . .., <br /> pied.) _. <br /> Original Signature: Date: 1 Z/31/ZOZS <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 />