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State of Oregon Department of Environmental Quality I�- �\u - '� "ctki5 <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 /> 19751 River Rd 042W1900500 <br /> Site Address: Parcel P. <br /> City' St Paul Marion <br /> County: <br /> 555-18-004946-PRMT <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: System Serial#: <br /> Report Year: 2025 9/30/2025 <br /> 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 /> O ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> O ❑ 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 /> ❑ f Is the system failing? <br /> ❑ In Discharge of sewage to the ground surface? <br /> O Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ I. 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#: RM 259 10/19/27 <br /> 'Certification Expiration: <br /> (*This line only can he filled qut and photocopied.) <br /> I�rM.l /t.�V1t 12/31/2025 <br /> Original Signature: v f Dale: <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 /> DFD Anwar ORR;atmn 3 no, Mar eenance Reonn Form Rev 6,2022 <br />