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„eryl. State of Oregon Department of Environmental Quality 073- do //6 7 <br /> Annual Operation and Maintenance <br /> Iri <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: MEGAN & TODD FORREST Phone: 503-859-4722 <br /> Site Address: 11008 DOGWOOD LN. SE Parcel#: 093E18AA00400 <br /> City. LYONS county: Marion <br /> 555-21-001059-PRMT <br /> Permit#: Start up date if 1st year in use: NA <br /> System Model#: PRESSURE DISTRIBUTION System serial#: NA <br /> Report Year: 2025 Date of Service Performed: 10/3/2025 <br /> Email Address: MTFORREST07@AOL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ 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❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> ❑--...- MI Discharge of sewage to the ground surface? <br /> ❑ II Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 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 can be out and photo•.pied.) <br /> Original Signature: �' 111 Date: 1 Z/31/ZOZ5 <br /> Note: Maintenance provi•ers mu` maintain accurate -cords of their maintenance contracts,customers, <br /> performance data,and ti relines fr r- •-wing the cont .cts. These records must be available for inspection upon <br /> request by the agency per • • - 0-071-0 • <br /> DFQ Annual Operation and Maintenance Report Form Rev 6:2022 <br />