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61, 1-1- LSO\o55-T State of Oregon Department of Environmental Quality Annual Operation and Maintenance DEQ Report Form General Information (Complete ALL information) Property owner: EAGLE TANKS Phone: (503) 749-4949 9055 PORTER WAY SE T9 R1 W S6 TL601 Site Address: Parcel#: City: AUMSVILLE County: MARION Permit#: 06-03634 Start up date if 1st year in use: System Model#: SANDFILTER System Serial#: Report Year: 2025 Date of Service Performed: 07/07/2025 Email Address: office.septech@gmail.com Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) Yes No x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? ❑ MI Is the system failing? ❑ Q Discharge of sewage to the ground surface? ❑ II Discharge of sewage to drain tiles or surface waters? ❑ In Sewage backup into plumbing fixtures? If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: I certify that this report is complete and accurate to the best of my knowledge. I understand that falsification of this report is grounds for revocation of my certification and/or civil penalties. *Maintenance Provider Name(please print): Tim York- Septic Technologies *Certification#: M592 *Certification Expiration: 03/26/26 ('This line only can be filled out and photocopied.) Original Signature: �J�7 Date: 12/31/2025 Note: Maintenance p • ders must maintain accurate records of their maintenance contracts,customers, performance data, and timelines for renewing the contracts. These records must be available for inspection upon request by the agency per OAR 340-071-0130(24).