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ta-o(5\Sga-Tr��4' <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> MICHAEL PRESTON 503-851-3206 <br /> Property Owner: Phone: <br /> Site Address: 5778 DAHL LN. Parcel#: 082W13D03400 <br /> City: AUMSVILLE County: Marion <br /> Permit#: 555-16-005078 Start up date if 1st year in use: 6/4/17 <br /> System Model it: AX2ORT System Serial#: 131274 <br /> Report Year: 2025 Date of Service Performed: 10/15/2025 <br /> Email Address: rebeccajand@yahoo.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ 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 /> ❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> El • Discharge of sewage to the ground surface? <br /> ❑ 0 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: 3/28/26 <br /> ('This line only can be led and ied.) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance provide mu t mai ain accurate cords of their maintenance contracts, customers, <br /> performance data,and timelf es r r ewing the contr s. These records must be available for inspection upon <br /> request by the agency per OA 0-0 1-0130(24). <br />