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State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property owner: Tom & Shelly Bernhardt Phone: 541-398-0982 <br /> Site Address: 4246 Lucier Ave. Parcel* <br /> 00 <br /> City: St. Paul OR 97137v �4Lrt county: Marion County <br /> permit et 55-t� 41O )-PRMT Start up date it 1st year in use: <br /> System Model#: AX'143133 System Serial#: RTU136885 <br /> Report Year. 2025 Date of Service Performed: 06/05/25 <br /> Email Address: Ofce(( aosnw.com <br /> Onsite wastewater treatment system status: (Do not profit( and photocopy checkboxes) <br /> Yes No <br /> ( ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> 2 0 is the system operating in accordance with the agent-approved design specifications? <br /> ®. 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ CR Is the system failing? <br /> ❑ W Discharge of sewage to the ground surface? <br /> ❑ 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): Matthew I andry American On Site <br /> 'Certification#: RM 172 rtiecation Expiration: O4/24/27 <br /> ('This One only can be filled out photocopied.) <br /> ^ Original Signature: Date: d'¢—d� <br /> -- Note:Maintenance prat ers mu aintain accurate records of their maintenance contracts,customers, <br /> performance data;andig el" s for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Ar n C�2rzf _ s: F . .. .r..'. .4..._._2 <br />