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State of Oregon Department of Environmental Quality I 66/ q/ /, /'r7 Q <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: KRISTINE MARTER & DAVID RHODES Phone: 541-521-1369 <br /> Site Address: 6058 STAYTON RD. Parcel#: 092W33A001900 <br /> City. TURNER county: Marion <br /> Permit#: 555-17-003507-PRMT Start up date if 1st year in use: NA <br /> AX2ORT 134120 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 2/1 1/2025 <br /> Email Address: KRISSYMARTER@YAHOO.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 /> lI ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> El ❑ 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 /> O 111 Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 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 thatthis 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 otopopied.) <br /> Original Signature: Date: <br /> 12/31/2025 <br /> Note: Maintenance oviders 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 /> Defi Annual Opeialion ann ra.Antaaianou lacyal Huai kec i 2!R2 <br />