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State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> win <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: DAVE PICK phone: 541-977-5871 <br /> 12023 W STAYTON RD. 555-08-07343 <br /> Site Address: Parcel#. <br /> City: AUMSVILLE county: Marion <br /> 08-07343 NA <br /> Permit Start up date if 1st year in use: <br /> PRESSURE DIST y NA <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: PICK_DAVE@YAHOO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> n ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> O ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ I] 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 be filled out and photocopied.) _-. <br /> Original Signature: "f ' )k° s- Date: 12/31/2025 <br /> Note: Maintenance providers must maintain accurate records of their maintenance contracts, customers, <br /> performance data,and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DLO Anr.pa Operation and MavLe'lance Report Fore <br />