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j7-ooO 31- (AIQ <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Propertyowner: DOUG RAUEN Phone: 503-347-3977 <br /> 20145 OLMSTEAD RD. NE Parcel#: 041W19B01200 <br /> Site Address: <br /> City: AURORA County: Marion <br /> 555-14-007566 Start up date if 1st year in use: N/A <br /> Permit#: <br /> System Model#: AX2O-RT System Serial#: 131138 <br /> Report Year. 2025 Date of Service Performed: 2/21/2025 <br /> Email Address: TOWNCAR@LIMO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q Li Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ • Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ I] 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#: M 587 •Certification Expiration: 3/28/2026 <br /> (*This line only can be led'ut and p • :••pi:d. <br /> 12/31/2025 <br /> Original Signature: to Date: <br /> Note: Maintenance providers ust -intain accur- e records of their maintenance contracts,customers, <br /> performance data, and ti - s for ren-• ' • the • tracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130 - • <br /> DEC Ranuai operat'an and Ma lntenance Report Fors Rev.62022 <br />