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State of Oregon Department of Environmental Quality /" g6 7''3 - /iY"t <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> MICHAEL ELIAS 503-551-6882 <br /> Property Owner: Phone: <br /> Site Address: 12123 NE SILVERTON RD Parcel#: 061W33 00800 <br /> City: SILVERTON County: Marion <br /> 555-05-07399 Start up date if 1st year in use: <br /> Permit#: NA <br /> System Model#: AX2ON System Serial#: 128739 <br /> Report Year: 2025 Date of Service Performed: 11/20/2025 <br /> Email Address: khourydevelopment@yahoo.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 /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> x❑ El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ I 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 Wes"on the last four questions,was a repair permit obtained? If not,explain: <br /> PONDING SEEN AT DRAINFIELD, WORKING ON REPAIRS. <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 fi ut and photo p=d.) <br /> a <br /> Original Signature: 1 C5 It , Date: 12/31/2025 <br /> Note: Maintenance providers us aintain accurate -cords of their maintenance contracts, customers, <br /> performance data, and timelines r - ewing the con acts. These records must be available for inspection upon <br /> request by the agency per OAR 340-07 -: r 2 <br /> DE0 Annual Operation and Maintenance It epos Form Rev 612022 <br />