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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: David & Cameron Buck 13vbc actvt3 gia.Phone: <br /> 5 3 iia yaa5 <br /> 9594 & 9604 Broadacres Rd. NE <br /> Site Address: Parcel#: <br /> City. Hubbard County: Marion <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: DF60 System Serial#: 4071 <br /> Report Year: 2025 Date of Service Performed. 6/30/2025 <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 /> 7�y ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Lry. ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Is the system failing? <br /> ❑ tat Discharge of sewage to the ground surface? <br /> ❑ �� Discharge of sewage to drain tiles or surface waters? <br /> ❑ it 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 d.) <br /> Original Signature: Date: 2M/2 <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 />