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A.State of Oregon Department of Environmental Quality Q2D_ tA.lB T t <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Coleman Ranch (503) 235-1777 <br /> Property Owner: Phone, <br /> 5235 Keene Rd NE 052W20 01700 <br /> Site Address: Parcel#: <br /> City: Gervais County: Marion <br /> 555-19-002600-PRMT <br /> Permit#: Start up date if 1st year in use: <br /> AX2ORT 140720 <br /> System Model#: System Serial#: <br /> 2025 4/8/2025 <br /> Report Year: Date of Service Performed: <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑x ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> ❑x 0 Is the system operating in accordance with the agent-approved design specifications? <br /> ❑x ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ E Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ • 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 print): Joseph Audas - Septic Technologies <br /> "Certification if: RM 259 "Certification Expiration: 10/19/27 <br /> ('This line only can be filledput and photocopied.) <br /> /' <br /> Original Signature: �./�. A..1/4_, Date: 12/31/2025 <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 /> DEO Hrnua:ooesio,i and Ma!nte=a.e Hepoe fr.o-rn Rev 6.2C22 <br />