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State of Oregon Department of Environmental Quality CX2V— <br /> ►y`_i Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: <br /> TOM EUBANKS Phone: 503-539-7005 <br /> 250 W SANTIAM AVE Parcel#: 105E02DA04700 <br /> Site Address: <br /> City: DETROIT county: Marion <br /> 22-001430 Start u date if 1st year in use: 06/19/2023 <br /> Permit*: p <br /> System Model*: AX2ORT System Serial#: 147145 <br /> Report Year: <br /> 2025 Date of Service Performed: 5/50025 <br /> Email Address: thomaseubanks@mac.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 0 ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ Discharge of sewage to the ground surface? <br /> El • 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*: M 587 'Certification Expiration: 3/28/2026 <br /> (*This line only calillegiut.and <br /> �p>ot copried.L <br /> Original Signature�T� _ UU Date: 12/31/2025 <br /> Note: Maintenance roviders st maintain acc to records of their maintenance contracts, customers, <br /> performance data,an 'melt s for renewing the ntracts. These records must be available for inspection upon <br /> request by the agency per OA - ). <br /> DEO Annual Operation and Maintenance Report Form Rev.6:2022 <br />