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• f-bcOW1 zr�R <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEq' Report Form <br /> General Information (Complete ALL information) <br /> Property Owner. et=d David & Cameron Buck �3 acvits P �'£ 3 qga�-tares <br /> 9574 & 9584 Broadacres Rd. NE parcel# <br /> Site Address: <br /> City: <br /> Hubbard county: Marion <br /> Permit#: Start up dale if 1st year in use: <br /> System Model#: °F60 System Serial it 4613 <br /> 2025 Date of Service Pertormed. 6/30/2025 <br /> Report Year <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> El Was maintenance performed as required by septic system rules and the manufacturer? <br /> i ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> R ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ V4 Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> 0 5. Discharge of sewage to drain tiles or surface waters? <br /> ❑ !t 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#: <br /> RM250 'Certification Expiration: 03/30/2027 <br /> ('This line only can be filled out and pho <br /> Original Signature: <br /> Date. 12/ r W25 <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 />