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State of Oregon Department of Environmental Duality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Friends Church / Ted Hazel Phone: 5D3— 371-4 a 4Li <br /> 520 Grandview Ave. NE <br /> Site Address: Parcel#: <br /> Scotts Mills Marion <br /> City: County: <br /> Permit#: Start up date if 1st year in use: <br /> DF50 24051 <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 /> / <br /> L i ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> r® ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Ibl ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 22 Is the system failing? <br /> El Et Discharge of sewage to the ground surface? <br /> ❑ t"1 Discharge of sewage to drain tiles or surface waters? <br /> ❑ ii 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 filled out and ph a d.) I <br /> Original Signature: Date: t/b72-6 <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 /> I]tr0 Annual Operaion and Alavnc-ancc Report Fonn Re. 62022 <br />