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State of Oregon Department of Environmental Quality 4'S— 9& ( 6 5-/ y <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: RACHEL & JUSTIN GUENTHER Phone: 541-543-1033 <br /> Site Address: 8703 SHAFF RD. SE Parcel it: 092W01 C 01900 <br /> City: TURNER County: Marion <br /> Permit#: 555-20-000461-PRMT Startup date if 1st year in use: NA <br /> System Model#: AQUA SAFE System Serial It: NA <br /> Report Year: 2025 Date of Service Performed: 7/29/2025 <br /> Email Address: RACHELMGUENTHER@OUTLOOK.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> a ❑ 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 /> ❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ NI Is the system failing? <br /> ❑ II Discharge of sewage to the ground surface? <br /> ❑ IN 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): Cory Morgan - A & B Septic Service <br /> *Certification#: M 587 "Certification Expiration: 3/28/2026 <br /> ("This line only can be ut and otom/ed.) <br /> Original Signature: <br /> Date: 12/31/2025 <br /> V <br /> Note: Maintenance providers u t maint-'n accurate re ords of their maintenance contracts,customers, <br /> performance data,and timelines or renew% the cont - s. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-013r - <br /> DEO Annual Operation and Maintenance Report Fain Rev.02022 <br />