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Iq- 1D-.11 Q -2 <br /> State of Oregon Department of Environmental Duality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Kiril & Dorocida Martushev <br /> Property Owner: Phone: <br /> 6694 Keene Rd. NE <br /> Site Address: Parcel#: <br /> Gervais Marion <br /> City: - County. <br /> Permit#: Stan up date if 1st year in use: <br /> System Model#: DF50 System Serial#: 22481 <br /> Report Year: 2025 Date of Service Performed: 8/12/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 0 0 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 /> IN ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ yi Is the system failing? <br /> ❑ Ea. Discharge of sewage to the ground surface? <br /> ❑ Ca Discharge of sewage to drain tiles or surface waters? <br /> ❑ t 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 tilled out and photo <br /> Original Signature: „ Date: IA /V <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 /> DI-0 Annual Ooc slion nn< Mainteronce Ka: rt norm ftr_;-.612022 <br />