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State of Oregon Department of Environmental Quality ' I_ u(s' V <br /> Annual Operation and Maintenance <br /> • <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Rick & Gloria Weitman <br /> Property Owner: Phone: <br /> 11610 Bear Ln. <br /> Site Address: Parcel#: <br /> ci Aumsville County: Marion <br /> Y <br /> Permit#: Start up date if 1st year in use <br /> System Model#: DF50 System Serial#: 25199 <br /> Report Year: 2025 Date of Service Perfom ed.• 11/3/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> r[yr L i Was maintenance performed as required by septic system rules and the manufacturer? <br /> �ry ❑ 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 /> ❑ E1 Is the system failing? <br /> ❑ ®. Discharge of sewage to the ground surface? <br /> ❑ E 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 codification 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 phot )Original Signature: �.ii�-yis Date: 1( /2g <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 /> DF.C.Anni Or ciion. kl ncryncc lEoot Ferm Rev -.2Lee <br />