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State of Oregon Department of Environmental Quality t j—MOOR p3 Q <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> James & Carrie Brassel <br /> Property Owner: Phone: <br /> 2892 Matheny Rd. NE <br /> Site Address: Parcel#. <br /> Gervais Marion <br /> City: County: <br /> Permit#: Start up date if 1st year in use: <br /> DF50 26494 <br /> System Model#: System Serial#: <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 /> Yes1 No TTT ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> I�Cy1ta 0 Is the system operating in accordance with the agent-approved design specifications? <br /> LLB ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ��}} Is the system failing? <br /> ❑ EL Discharge of sewage to the ground surface? <br /> ❑ 154 Discharge of sewage to drain tiles or surface waters? <br /> ❑ El Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> 1 beftiiythalThis 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 d.) // / <br /> Original Signature: Date: 1/ b 4 <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 /> r]FOA I r [ nurn nod toodonnoco knoiond Form Km. r�JO?9 <br />