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State of Oregon Department of Environmental Quality /7-161 (/r+ z 7—/N <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: CARSON KUENZ1 Phone: 503-428-6131 <br /> Site Address: 3320 ALT LN. NE Parcel#: 071W07D01000 <br /> City: SILVERTON County: Marion <br /> Permit#. 555-13-005876 Start up date if 1st year in use: 9/4/15 <br /> System Model#: AX2ON System Serial#: 130725 <br /> Report Year: 2025 Date of Service Performed: 2/18/25 <br /> Email Address: CARSON@PACSAN.NET <br /> Onsite wastewater treatment system status: (Do not preffll and photocopy checkboxes) <br /> Yes No <br /> ❑ - ❑ - Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ MI Discharge of sewage to the ground surface? <br /> ❑ IN 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): MAGNUM MILLER - A & B Septic Service <br /> *Certification#: RM 174 'Certification Expiration: 4/24/2027 <br /> (*This line only can be filled out and photocopied.) <br /> 12/31/2025 <br /> Original Signature: i� <br /> Date: <br /> Note: Maintenance pr iders 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 /> ❑Fd Annual(Mora:ion and Mvntonance lepna Form nnni 62022 <br />