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State of Oregon Department of Environmental Quality /71 &0i) —1 <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JEFF KAUFFMAN Phone: 503-319-3659 <br /> Site Address: 9655 IDA LN. Parcel#: 041 W19B 01801 <br /> City' AURORA County: Marion <br /> Permit#: 13-00377 Start up date if 1st year in use: UNKNOWN <br /> DELTA WHITE WATER DELTA <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 8/18/2025 <br /> Email Address: Jkauffman2236@msn.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 /> I] ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I• Is the system failing? <br /> ❑ I>] Discharge of sewage to the ground surface? <br /> ❑ El Discharge of sewage to drain tiles or surface waters? <br /> ❑ MI Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> certify-Hi-ant 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 filled out and photocopied.) <br /> Original SJgrrtur S� Date: 12/31/2025 <br /> Note: Maintenance provid rs r maintain a urate records of their maintenance contracts,customers, <br /> performance data,and tim- 1- for r- ild e contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual Operaton and Maintenance Report For- Rev 62022 <br />