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a 5-c b 15 <br /> State of Oregon Department of Environmental Duality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Travis Smith Phone. 503-881-3371 <br /> 4855 Cody Ln. SE <br /> Site Address: Parcel# <br /> Salem Marion <br /> City: County. <br /> Permit#: Start up date if 1st year in use: Sep 22 <br /> System Model#: AS600L System Serial#: B002991 <br /> Report Year: 2025 Date of Service Performed: 5/9/2025 <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 /> rl�l ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> lye ❑ 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 /> ❑ at Discharge of sewage to drain tiles or surface waters? <br /> ❑ ix 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 /> 'Certfication#: RM250 'Certification Expiration: 03/30/2027 <br /> ('This line only can be filled out and photo // rr <br /> Original Signature: Date: ( Z'V <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 /> !-JEc,Annual Opera:iona 1 i t'.nBnce Report Fo'IO Rai p,2UYZ <br />