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ai}-Cptfik-siNQY RECEIVED <br /> State of Oregon Department of Environmental Duality APR 0 2 2026 <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Melissa LaCrosse 503-302-8248 <br /> Property Owner: Phone: <br /> 5952 A St. SE <br /> Site Address: Parcel#: <br /> Turner Marion <br /> City: County: <br /> Permit#: Start up date if 1st year in use: Sep 22 <br /> AS600NR NR002595 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 1 1/3/2025 <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> ;As No <br /> r`p./�' ❑ 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 /> ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Is the system failing? <br /> ❑ IX Discharge of sewage to the ground surface? <br /> ❑ M Discharge of sewage to drain tiles or surface waters? <br /> ❑ vi 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 /> repod 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 pho ) /[� <br /> Original Signature: � Date: I 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 /> IJ.O Annual Operation and Maintenance Re par]Four Rev.6/2022 <br />