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State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> pEQ Report Form <br /> General Information(Complete ALL information) <br /> Property owner Gary& Linda Williams phone: 503-795-8005 <br /> Site Address: 25897 Taylor Park Pew g. 092E10DC00400 <br /> City: Lyons county: Marion County <br /> Reims* Start Start up date if 1st year in use: <br /> 10/04/2023 <br /> System Model fk Ax2DRT System Serial lk. ORD 540420-1 <br /> Report Year.. 2025 Date of Service Performed: 12/16/2025 <br /> Email Address: nforkwltageOwvi.com <br /> Onsite wastewater treatment system status: (Do not prefl)i and photocopy checkboxes) <br /> Yes No <br /> 17 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> st Q Is the system operating in accordance with the agent-approved design specifications? <br /> CS 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing?. <br /> ❑ 14 Discharge of sewage to the ground surface? <br /> ❑ 21 Discharge of sewage to drain tiles or surface waters? <br /> ❑ N 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 prinp: Bennett Septic Service LIS(Amber Bennett) <br /> tertigcadon V: RM245 *Certification Expiration: 03/30/2027 <br /> ("This fine only can be filled out and hotacopied.)Original Signature c Data: Di-07-240 <br /> Note:Maintenance providers must maintain accurate records of their maintenance contracts,customers, <br /> performance data,end 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 /> DEO Annual Operation and Maintenance Repot Form Rev.6/2022 <br />