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1.1. e 98W3tQ <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Jennifer Fessler <br /> Property Owner: Phone: <br /> 13573 Marquam Rd. NE <br /> Site Address: Parcel#: <br /> ci Mt. Angel county: Marion <br /> ty <br /> Permit#: - - - Start up date if 1st year in use: <br /> DF50 23633 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 5/6/2025 <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 manufactures? <br /> E,1 r {l El Is the system operating in accordance with the agent-approved design specifications? <br /> l,�, ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> El a Is the system failing? <br /> ❑ t Discharge of sewage to the ground surface? <br /> ❑ Discharge of sewage to drain tiles or surface waters? <br /> ❑ IR 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 Original Signature: Date: 1/4 //LC <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 /> I]6OA IOperalnne I ncea oo'i Fuiin Eev.6i2C22 <br />