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State of Oregon Department of Environmental Quality I8- (poll 83=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 /> 16073 French Prairie Rd NE Parcel#: 052W07 00200 <br /> Site Address: <br /> Woodburn County: Marion <br /> City: <br /> 555-16-008024 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: System Serial#: <br /> 2025 9/30/2025 <br /> Date of Service Performed: <br /> Report Year: <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 ❑ 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 /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ Q 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#: <br /> RM 259 10/19/27 <br /> 'Certification Expiration: <br /> (*This line only can be filled qut and photocopied.) <br /> 1� 12/31/2025 <br /> Original Signature: V �• Date: <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 /> DFQ Annual Operation and Ma Renance Recoi.-o m Rev A2C22 <br />