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I - ec-mC\55-V\VR <br /> State of Oregon Department of Environmental Quality <br /> MAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: CRYSTAL SMITH Phone: 971-221-9108 <br /> Site Address: <br /> 319 4TH ST Parcel#: 061E22AB00900 <br /> City: SCOTTS MILLS county: Marion <br /> Permit#: 05-03855 Start up date if 1st year in use: 6/13/5 <br /> System Model#: AX2ON System Serial#: 105220 <br /> 2025 Report Year: Date of Service Performed: 1 Z/1/2OZ5 <br /> Email Address: crystal.smith1979@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> ▪ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ In Discharge of sewage to the ground surface? <br /> ❑ • 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 /> !:eReiy 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 andfor civil penalties. <br /> *Maintenance Provider Name (please print): Cory Morgan - A & B Septic Service <br /> *Certification it: *Certification 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can b rid out and photocopied.) <br /> 12/31/2025 <br /> Original Signature _ Date: <br /> Note: Maintenance providers m t maintain a vote records of their maintenance contracts, customers, <br /> performance data,and ti ' s renewing t contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340- 1-0130(2 ). <br /> DEO Annual Operation and Maintenance Report Form Rev.62022 <br />