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State of Oregon Department of Environmental Quality I I-l..J--u-- I ©� '"�. <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Jeffrey & Solomonia Clipfell <br /> Property Owner: Phone: <br /> 6947 Quarry Rd. NE <br /> Site Address: Parcel#: <br /> Silverton Marion <br /> City: County: <br /> Permit#: -- Start up date if 1st year in use: <br /> System Model#: DFSO System Serial#: 25902 <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 /> ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> a ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> 1 ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I //, Is the system failing? <br /> ❑ Discharge of sewage to the ground surface? <br /> ❑ IS, 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 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 p .) <br /> Original Signature: Date: t/b/Zb <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 /> oeo a ,l opm..ior, i :mre 12,...., I <br />