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State of Oregon Department of Environmental Quality t 1— PO Q, 4a ItJ Q <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Mark & Paula Pietrok <br /> Property Owner: Phone: <br /> 9743 Pennstar Ln. NE <br /> Site Address: Parcel#: <br /> Aurora Marion <br /> City: County: <br /> Permit#: Start up date it 1st year in use: <br /> DF50 26900 <br /> System Model#: System Serial#: <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 /> ❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> T . ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IT Is the system failing? <br /> ❑ [51 Discharge of sewage to the ground surface? <br /> ❑ ®, Discharge of sewage to drain tiles or surface waters? <br /> ❑ El Sewage backup into plumbing fixtures? <br /> If you answered'Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> rcertity 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 phut a ' <br /> 2,6 <br /> Original Signature: Date: A/ <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 /> vb0AnnualOpera-ion and dlandonance Report Form <br />