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l�f t lsl�-1 'It <br /> State of Oregon Department of Environmental Duality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Paul & Dana Gibbons / jz7- 4 .51/0 <br /> Property Owner: Phone: r <br /> Site Address: 9695 Ida Ln. NE <br /> Parcel#: <br /> Aurora y. Marion <br /> City: Count <br /> Permit#: Start up date if 1st year in use: <br /> DF50 26444 System Model#: <br /> System Serial If: <br /> Report Year: 2025 6/30/2025 <br /> P Date of Service Performed: <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> g ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> ® ❑ 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 /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ El Discharge of sewage to drain tiles or surface waters? <br /> Q ISKI 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): Austin Arts <br /> *Certification#: RM250 'Certification Expiration: 03/30/2027 <br /> ('This line only can be filled out and et d.) <br /> Original Signature: Date: Ai 41 <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 /> DEOAnimal )peraior.and n tc,anm-itimpd ai. 'i inv.612022 <br />