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ail- Occf\e4 9:71 <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: OREGON RESOURCE Phone: (503) 569-296 <br /> 5525 DISCOVERY PL NE Parcel#: T7S R2W S28BC TL500 <br /> Site Address: <br /> city: SALEM county: MARION <br /> Permit#: 05-05483 Start up date if 1st year in use: <br /> System Model#: <br /> 3 AX20N System Serial#: <br /> Report Year. 2025 Date of service Performed: 11/04/2025 <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not preffll and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ I 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 certifiration and/or civil penalties. <br /> *Maintenance Provider Name(please primp. Tim York - Septic Technologies <br /> *Certification#: M592 *certification Expiration: 03/26/2026 <br /> ('This line only can be filled out and photocopied.) <br /> 12/31/2025 <br /> Original Signature: <br /> Date. <br /> Note:Maintenance p d s 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 /> orr. ars,, ial� <br />