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Q151—000436-11JQ'P <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL infomtadon) <br /> property owner Josh Williams Phone: 503-678-5966 <br /> Site Address: 12810 Ehlen Rd. Ne Parcel#: <br /> city Aurora OR 97002 County: Marion County <br /> Permit#: 555-23-009312 Start up date if 1st year in use: <br /> System Model#: AX-162207 System Serial ft RTU149109 <br /> Report Year. 2025 Date of Service Pei IV]nIed: 09/17/25 <br /> 7 Email Address:Ofhcec8 aOSnw.corn <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> r[.,,f( ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> 1� El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ES Is the system failing? <br /> ❑ 5, Discharge of sewage to the ground surface? <br /> ❑ EX Discharge of sewage to drain tiles or surface waters? <br /> ❑ nc Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If riot,explain: <br /> I certify'that this report is complete and accurate to the best of my kn•, -dge. I understand that falsification of this <br /> report Is grounds for revocation of my certi don and/or civil penal( -. <br /> 'Maintenance P ider Name(please print): tr- r e- , andry American On Site <br /> 'Certification#: RM 172 'Certification Expiration: 04/24/27 <br /> ('This line only can filled out and ph ied.) <br /> Original Signature: f Date: 09/17/25 <br /> Note: Maintenance pray( must maintai '=ccurate records of their maintenance contracts,customers, <br /> performance data,an melines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEQ andlJaml'^aree Rev,:Ft Rev.E2^22 <br />