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18-(tcs1Le <br /> State of Oregon Department of Environmental Duality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Dana Slyter <br /> Property Owner: Phone: <br /> 11451 Hook Rd. NE <br /> Site Address: Parcel#: <br /> Mt. Angel <br /> City: g County Marion <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: DF50 System Serial#: 25563 <br /> Report Year: <br /> 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 /> ❑ 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 /> ❑ Eg. Is the system failing? <br /> ❑ ®, Discharge of sewage to the ground surface? <br /> ❑ Discharge of sewage to drain tiles or surface waters? <br /> ❑ [ Sewage backup into plumbing fixtures? <br /> If you answered'Yee 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 ' d.) �. <br /> Original Signature: Date: (/CZ <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 /> DEC)Annual Op)Au'ion and d]amm^an_e Itnaat Four 9r. n2022 <br />