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Th-ccb 7s:110a.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: Morris Family Trust Phone: <br /> 22105 Jennie Rd. SE <br /> Site Address: Parcel#: <br /> Lyons County: <br /> Marion <br /> City: <br /> Penult#: Start up date if 1st year In use: — . --- <br /> System Model#: AS600NR NR001982UV <br /> System Serial#: <br /> Report Year: 2025 5/16/2025 <br /> Date of Service Performed. <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 /> El ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ RI Is the system tailing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> 0 ® 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 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 phot [ <br /> Original Signature: .�w� Date: 1/v/ 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 340-071.0130(24). <br /> DEC Annual Operation and Maintenance Repot Form IYev 6,20' <br />