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State of Oregon Department of Environmental Quality 023-0ja 79- /4' <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> TED & JUSTINE FERRY 503-399-0550 <br /> Properly Owner: Phone. <br /> 210 N BOULDER ST 105E01BC08800 <br /> Site Address: Parcel#: <br /> city: DETROIT County: Marion <br /> Permit#: 555-21-004943 Start up date if 1st year in use: N/A <br /> System Model#: SEEPAGE BED System Serial#: N/A <br /> Report Year: 2025 Date of Service Performed: 8/22/2025 <br /> Email Address: JUSTIN EFERRY@comcast.net <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 /> E ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ .1 <br /> Is the system failing? <br /> ❑ It Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ in 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): Coy Morgan - A & B Septic Service <br /> *Certification#: M 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can Wed out an. ••• .t• •. <br /> Original Signature: 9b ' - Date: 12/31/2025 <br /> Note: Maintenance •roviders m -t intain accurate r cords of their maintenance contracts,customers, <br /> performance data, an• -lines -•r rene• •• the con .cts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual Operation and Maintenance Report t arm Rev et2D22 <br />