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ail-b�ol�bb=_rr�Q� <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenanc <br /> DEQ <br /> Report Form <br /> General information (Complete ALL information) <br /> Property Owner. Youth WithAMission Phone: 859-3022557 <br /> Site Address: 7099 Battle Creek Rd Se Parcel#: <br /> city: Salem OR 97317 County: Marion <br /> 555-22-009129-PRMT <br /> Permit#: Startup date If 1st year in use: <br /> System Model#: AX-157108 System Serial#: RTU14 74 <br /> Report Year. 2025 Date of Service Performed: d- "9' -J-.f <br /> Email Address:OffICe(dac5nw.COr <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkbo es) <br /> Yes No <br /> ❑ 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 /> a ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ [, Is the system failing? <br /> ❑ r, 55® Discharge of sewage to the ground surface? <br /> L]❑ I 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 /> II <br /> I certify that this report is complete and accurate to the best of my knowledge. I understand that faisificatIon of tpis <br /> report is grounds for revocation of my certification and/or civil pen - III <br /> 'Maintenance trier Name(pleas print): American On Site <br /> 'Certificatio #: RM 172 'Ca Ilan Expiration: 04/24/27 <br /> ('This line an n be filled out and p led.) <br /> Original Signature: �- Date: <br /> Nate:Maintenance viders must malnta n accurst ecords 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 />