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„erg State of Oregon Department of Environmental Quality /q w/D7.J '/Nb y <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: LUKE FITZPATRICK Phone: 503-930-9431 <br /> 6266 HUNSAKER RD. SE Parcel#: 092W1600600 <br /> Site Address: <br /> city: TURNER county Marion <br /> Permit#: 555-14-004304 Start up date if 1st year in use: NA <br /> System Model#: SANDFILTER System serial#: NA <br /> Report Year: 2025 Date of Service Performed: 7/29/2025 <br /> Email Address: LFITZPATRICK1515@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ 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] El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 111 Is the system failing? <br /> ❑ is Discharge of sewage to the ground surface? <br /> 0 • Discharge of sewage to drain tiles or surface waters? <br /> ❑ IM 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 •Certifwtion Expiration: 3/28/2027 <br /> (*This line only can c -• out and p otocopied.) <br /> /�� 12/31/2025 <br /> anginal Signatur- �.� lr�1i - _ Date: <br /> Note: Maintenance proti• ust maintain .ccurate records of their maintenance contracts, customers, <br /> performance data,and tim- -s -newing he contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0 0(24). <br /> DEO Annual Operation and Maintenance Report Form Rev.6/2022 <br />