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4_Ertl State of Oregon Department of Environmental Quality / DDDO / 7— <br /> tial Annual Operation and Maintenance <br /> vie <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: Tim Kauffman 503-364-2438 <br /> Phone: <br /> Site Address: 12656 Chelsea Lane 051 W25DC00301 <br /> Parcel#: <br /> City: Mt Angel Marion <br /> County: <br /> 04-06659 <br /> Permit#: Start up date if 1st year in use: NA <br /> System Model itAX20 1 B 117261 <br /> System Serial#: <br /> Report Year: 2025 11/12/2025 <br /> Date of Service Performed: <br /> Email Address: ktkauff2@aol.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> i] ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> O ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> O El Is the system currently under a service contract with a certified maintenance provider? <br /> El El Is the system failing? <br /> El El Discharge of sewage to the ground surface? <br /> ❑ El Discharge of sewage to drain tiles or surface waters? <br /> ❑ III 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): Cory Morgan - A & B Septic Service <br /> *Certification it: M 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can be filled photocopied.) <br /> Origka-signeru Date: 12/31/2025 <br /> Note: Maintenance providers ust maintain acc ate records of their maintenance contracts,customers, <br /> performance data, and timelin for renewing the tracts. These records must be available for inspection upon <br /> request by the agency per OAR -0130,2 . <br /> DE(t)Annua.Operation snd cance Reoor{arm <br /> Rev 6�2]22 <br />