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11-CiLl069 961 IN <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Alan & Catherine Rauda <br /> Property Owner: Phone: <br /> Site Address: 6647 Quarry Rd. NE Parcel#. <br /> ci v <br /> Silverton count Marion <br /> y: <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: DF50 System Serial#: 26650 <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 /> cystt Li was maintenance performed as required by septic system rules and the manufacturer? <br /> Ly ❑ 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 /> ❑ 12, Is the system failing? <br /> ❑ Et Discharge of sewage to the ground surface? <br /> ❑ [`a Discharge of sewage to drain tiles or surface waters? <br /> ❑ txl 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 /> `Certfication#: RM250 *Certification Expiration: 03/30/2027 <br /> (*This line only can be filled out and phot pied.) / <br /> Original Signature: Date: I Cl z-C <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 340-471-0130(24). <br /> 1:1-0 Annual rp r,ron nnd Atniniananca It ro-t Farm Ito-, <br />