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ao 000a59-zNzp <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: DETROIT CITY PARK Phone: (503) 854-3496 <br /> 110 PATTON RD S T1OS R5E S2 TL100 <br /> Site Address: Parcel#: <br /> City: DETROIT County: MARION <br /> Permit#: 555-18-002474-PRMT Start up date if 1st year in use: <br /> System Model#: 2 AX20N System Serial#: <br /> Report Year: 2025 Date of Service Performed: 05/07/2025 <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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ MI 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 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: f Date: 12/31/2025 <br /> Note: Maintenance pro ' ers 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 /> CY1 Acr. If UDfl anC r anal ,i _m2022 <br />