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09s-0b0 &PI-TAb.q <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property owner: Andrew Bering Phone: 503-9454027 <br /> Site Address: 13528 E Marquam Rd Parcel#: <br /> Chy: Mount Angel OR 97362 County: Marion <br /> Permit#: 555-17-007137 <br /> Startup date if 1st year in use: <br /> System Model#: AX-144986 System Serial#: RTU137993 <br /> Report Year: 2025 Date of Service Performed: 1 161 19S <br /> Email Address:Office(dtaosnw.eom <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 /> • ❑ 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 /> ❑ Eg Discharge of sewage to the ground surface? <br /> ❑ El-y Discharge of sewage to drain tiles or surface waters? <br /> ❑ a 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 accu .to to the best of my kno ,••e. I understand that falsification of this <br /> report is grounds for revocation of my can and/or civil pen: ,a. <br /> *Maintenance Provider Name(• ease print): u. t,A, .:r•s a it -i : t •• <br /> *Certification#: RM 172 *Certification Expiration: 04/24/27 <br /> (•This line only can be filled • and photo-. <br /> �.� Original Signature: 0F Date: � <br /> Note:Maintenance providers ust main :In accurate records of their maintenance contracts,customers, <br /> performance data,and ti •-Ines for renewing the contracts. These records must be available for inspection upon <br /> request by the agen •er OAR 340-071-0130(24). <br /> DEC A^ru !TerYi r.alai t 'e•p,'.-e Re o]Fa-xt e :.45 2;2 <br />