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1 _ State of Oregon Department of Environmental Quality 4 \'-bb\o 3 5-I VC <br /> Annual Operation and Maintenance <br /> win <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Helicopter Transport Service Phone: 503-776-9300 <br /> Site Address: 14497 Keil Rd NE Parcel#: <br /> City: Aurora County: Marion <br /> Permit#: 10-05828 Start up date if 1st year in use: <br /> System Model#: AXZON B 6-Pod System Serial#: <br /> Report Year: 2025 Date of Service Performed: 5/9/25, 11/7/25 <br /> Email Address: smiths@htshelicopters.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> r-- 0 - Was maintenance performed as required by septic system rules and the manufacturer? <br /> ® 0 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 /> ❑ ® 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): Dylan Walters <br /> 'Certification#. RM 277 *Certification Expiration: 08/30/2028 <br /> ('This line only can be filleddoouut'and�phho(toocopied.) /7 <br /> Original Signature: U/� 14t1j9 Date: [I`L/T <br /> Note: Maintenance providers 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 /> DEQ Annual Operation and Maintenance Report Form Rev 6/2022 <br />