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Ili.— eboS TAQ <br /> "' State of Oregon Department of Environmental Quality <br /> sr Annual Operation and Maintenance <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property Owner. Charles Eggert Phone: 503-805-7805 <br /> Site Address: 23355 Butteville Rd Ne Parcel#: <br /> City: Aurora OR 97002 County: Marion <br /> Permit#: 555-21-002920 Start up date 81st year In use: <br /> System Model#: AX-127499 System Serial#: RTU123579 <br /> Report Year: 2025 Date of Service Performed: I I (P I2.5 <br /> Email Address: OfCe(aaosnW.CDm <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> El. ❑ 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 codified maintenance provider? <br /> ❑ '51 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 Nes'on the last four questions,was a repair permit obtained? If not,explain: <br /> I certify thatihtsreport Is complete and accurate to the best of my knowledge. I understand that falsification of th s <br /> report is grounds for revocation of my certification and/or civil penalties. <br /> 'Maintenance Provider Name(please print): Matthew Landry American On Site_ <br /> 'Certification#: RM 172 'Certification Expiration: 04/24/27 <br /> ('This line only can be fill-• •ul a • • otocopied: <br /> �-. Original Signature: c Date: 7 ^/ ( "Pect — <br /> Note:Maintenanc: •ro •ers mu Intain accurate records of their maintenance contracts,customers, <br /> performance data,and timelines for renewing the contracts. These records must be available for inspection upoi <br /> request by the agency per OAR 340-071-0130(24). <br /> 0a0 +c.,.,1'...n ,reran:R .rt F- r. R.. ..s::_z <br />