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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 Mark & Karen Keller Phone: 405-623-9223 <br /> 135 Hill St. <br /> Site Address: Parcel#: <br /> Detroit Marion <br /> City: County. <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AS500L system serial#: A067279 <br /> Report Year: 2025 Date of Service Performed: 5/16/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> lit% ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> tiq ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Ert ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ El� Is the system tailing? <br /> ❑ jai. Discharge of sewage to the ground surface? <br /> ❑ Mt Discharge of sewage to drain tiles or surface waters? <br /> ❑ 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 emit)! Austin Arts <br /> *Certification#: RM250 *Certification Expiration: 03/30/2027 <br /> ('This fine only can be filled out and ph a .) <br /> Original Signature: Date: 1( �lZK <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 />