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8-CO)U71.o:TAO <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> Ira <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: SEAN POTTER Phone: 503-949-7278 <br /> s eAddress: 180 PARKSIDE CT. Parcel 061E15C01700 <br /> City: SCOTTS MILLS County: Marion <br /> 555-17-003244 10/27/17 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: 136006 <br /> Report Year: 2025 Date of Service Performed: 8/5/2025 <br /> Email Address: flotowndunerO@hotmall.corn <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 /> I] ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> El Q 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 /> ❑ Q 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 ,e filled opt and p opied.) <br /> Original Signatur- t „ /I�- Date: 12/31/2025 <br /> Note: Maintenance providers m .t m.intain accurat= records of their maintenance contracts, customers, <br /> performance data, and timelin• ,•r r> ewing the •• tracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-1 1(24). <br /> DEG Annual Operation and Maintenance Report Form Rev 6/2022 <br />