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D427 5—/N4 <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: MARK DANIEL Phone: 503-849-8120 <br /> Site Address: <br /> 3974 MISSION RD Parcel#: 042W19B000204 <br /> city: ST PAUL coun y: Marion <br /> 10-05498 Start up date if 1st year in use: 10/14/10 <br /> Permit#: <br /> System Model#: AX2ON System Serial#: 122215 <br /> Report Year: 2025 Date of Service Performed: 1/15/2025 <br /> Email Address: markdaniel@stpaultel.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> • ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ 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 /> ❑ it Discharge of sewage to drain tiles or surface waters? <br /> ❑ It 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: 4/24/27 <br /> ('This line only can be filled out and hotocopied.) <br /> Original Signature: �/ / Date: 12/31/2025 <br /> Note: Maintenance roviders 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 />