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11-oo 53-It 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 /> SILVER FALLS SCHOOL DIST.-EVERGREEN SCHOOL (503) 873-5303 <br /> Property Owner: Phone: <br /> Site Address: 3727 CASCADE HWY NE Parcel#: T7 R1W S9A TL900 <br /> City: SILVERTON County: MARION <br /> 06-07369 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX20 3B System Serial#: 110023 <br /> Report Year: 2025 Date of Service Performed: 08/04/2025 <br /> Email Address: ofce.septech@o gmaiI.corn <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 /> .❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> ❑ In Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ Is 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): Tim York- Septic Technologies <br /> *Certification#: M592 `Certification Expiration: 03/26/26 <br /> (*This line only can be filled out and photocopied.) <br /> Original Signature: � Date: <br /> 12/31/2025 <br /> Note: Maintenance pr iders 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 />