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a'Q- State of Oregon Department of Environmental Quality / 7- OD✓ (0L5-5-/N, <br /> Annual Operation and Maintenance <br /> Willi <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: IGNATY EGOROFF Phone 503-930-5019 <br /> Site Address: 17511 S. ABIQUA RD Parcel#: 061E28CB00900 <br /> City: SILVERTON county: Marion <br /> Permit#: 10-03800 Start up date if 1st year in use: 7/8/10 <br /> AX2ORT 121414 <br /> System Model#f. System Seral#. <br /> Report Year: 2025 Date of Service Performed: 12/02/2025 <br /> Email Address: IGGY@BNICONST.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 /> D ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ In Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ IN Discharge of sewage to drain tiles or surface waters? <br /> ❑ II 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#: *Certification 587 "Certification Expiration: 3/28/2026 <br /> ('This line only can be filed t an hotocopi ) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance proC ers mu mainta accurate recor s of their maintenance contracts, customers, <br /> performance data,and tim . r renewi a contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24 . <br /> DEQ Annual Operation and Maintenance Repor Ponn Rev.6/2022 <br />