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State of Oregon Department of Environmental Quality /7—0D0 d Z 5- /k <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: JIM ENGELMANN Phone: 503-931-5818 <br /> 255 HUMBUG ST. 105E01CB02200 <br /> Site Address: Parcel#: <br /> City: DETROIT county: Marion <br /> Permit#: Start Start up date if 1st year in use: NA <br /> System Model#: AX2ON System Serial#: 114122 <br /> Report Year: 2025 Date of Service Performed: 5/5/2025 <br /> Email Address: plunor@msn.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 /> I] ❑ 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 /> ❑ It Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ I] 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#: 87 'Certification Expiration: 3/28/2026 <br /> ('This line only can a fill out and ph ,copied.) <br /> ..dos La Date: 12/31/2025 <br /> Note: Maintenance pr..v ders st maintain acc rate records of their maintenance contracts, customers, <br /> performance data,and ti es •r renewing th contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-• 4). <br /> DEG Annual Operation and Maintenance ReportFeral Rev 62C22 <br />