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a(p- 4 \- Qy <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Miguel Sanchez <br /> Property Owner: Phone: <br /> 7060 Wapato St. NE <br /> Site Address: Parcel#: <br /> City: Salem Q County: Marion <br /> Permit#: 07 3- �V[ ' V�4`T T p trnT Start up date if 1st year in use: <br /> System Model#: AS500L System Serial#: <br /> Report Year: 2025 Date of Service Performed: 5/9/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> VIEl 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 /> tRz ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ RI Is the system failing? <br /> O (t Discharge of sewage to the ground surface? <br /> ❑ 121 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): Austin Arts <br /> *Certification#: RM250 `Certification Expiration: 03/30/2027 <br /> (*This line only can be filled out and photo Original Signature: /l Date: • A <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 /> GFO Annual fJ unan.l l rce Hem✓I Enon <br />