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565- Zq-wqq$5.- (Ala <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information(Complete ALL information) <br /> Richard Berkey <br /> Property Owner: Phone: <br /> 35315 Ruth St. <br /> Site Address: Parcel#: <br /> City: Lyons county: Marion <br /> Permit It: Start up date if 1st year in use: <br /> System Model#: AS600NR system Serial#: NR002503UV <br /> Report Year: 2025 Date of Service Performed: 5/16/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ® 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> • ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> ❑ &i Discharge of sewage to the ground surface? <br /> ❑ (`] Discharge of sewage to drain tiles or surface waters? <br /> ❑ 64 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 p ed.) /L <br /> Original Signature: Date: ' 4/2c <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 /> DEO Annual Operation and naainter ante Report Form Rev.612022 <br />