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CVtOg3t <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: JERRY & KIM PETERSON Phone: 360-584-8811 <br /> 4927 HOME RUN LN. SE Parcel#: <br /> 092W20001700 <br /> Site Address: <br /> cry: TURNER county: Marion <br /> Permit#: 05-01896 Start up date if 1st year in use: NA <br /> System Model#: SANDFILTER System Serial#: NA <br /> Report Year: 2025 Date of Service Performed: 4/16/2025 <br /> Email Address: peterson.jerry@CJComCaSt.net <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 /> a ❑ 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 /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ In Discharge of sewage to drain tiles or surface waters? <br /> ❑ ® 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 b Ilethout and photocop <br /> Original Signature: ifiVirt 'Pr <br /> Date: 12/31/2025 <br /> Note: Maintenance providers must aintain -- rate record-of their maintenance contracts, customers, <br /> performance data, and timelin-- or -newing the •• - . ese records must be available for inspection upon <br /> request by the agency per OAR 34.-471-0130(24). <br /> DEQ Annual Operation and Maintenance Repor: C: in Re¢o:pp22 <br />