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05-ect3a5-17i)uzy <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Intonation) <br /> Property owner. Stephen Hemminger Phone: 503-307-1451 <br /> Site Address: 10921 Martin Ln Ne. Parcel It <br /> city: Aurora OR 97002 county: Marion County <br /> Permit#: #555-23-003841 Start up date If 1st year in use: <br /> System Model#: AX-158122 System serial#: RTU148519 <br /> Report Year. 2025 Date of Service Performed: (p I%CA 25 <br /> Email Address:OfficeRgaosnw.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy cheekbones) <br /> Yes No <br /> ] 0 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 /> IR ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Is the system failing? <br /> ❑ N Discharge of sewage to the ground surface? <br /> ❑ Qr1 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 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(plea - u- t r - -, d a / American On Site <br /> tertficatlon#: RM 172 Aired'. - Expiration: 04/24/27 <br /> (This fine only can be filled out .nd photo-cop'. •.) f <br /> Odginal Signature: Date: sir <br /> _`� <br /> Note: Maintenance providers . st maintain accurate records of their maintenance contracts,customers, <br /> performance data,and a - nes for renewing the contracts. These records must be available for inspection upon <br /> request by the agency r OAR 340-071-0130(24). <br /> DEQ Ar.:al aed 6te...- a_ r pc.^.F:: Re..66:22 <br />