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IC\—ecoa4a-D <br /> State of Oregon Department of Environmental Duality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Irene & Robert Butsch <br /> Property Owner: ,., Phone: <br /> Site Address: 8466 May Rd. NE Parcel#: <br /> Mt. Angel Marion <br /> City: County: <br /> Permit#: Start up date if 1st year in use: <br /> DF50 27644 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 5/6/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 14 -❑ -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 /> Ib, ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 15, Is the system failing? <br /> ElEl Discharge of sewage to the ground surface? <br /> ❑ . Discharge of sewage to drain tiles or surface waters? <br /> ❑ 21, Sewage backup into plumbing fixtures? <br /> If you answered Wes'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 'rrt.) <br /> Original Signature: Date: 1 /06 <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 /> ➢EO Annuol Opu oboe and Maintenance It6066 Om' Rov.6.2022 <br />