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aa-Co�g33 � <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: LARRY MOORE Phone: 503-910-0391 <br /> 1057 MEADOWS LN. Parcel#: 093W15B000202 <br /> Site Address: <br /> City. JEFFERSON County Marion <br /> Permit#: 555-20-007279 Start up date if 1st year in use: NA <br /> System Model#. AX20RT System Serial#. 145017 <br /> Report Year: 2025 Date of Service Performed: 12/04/2025 <br /> Email Address: LARRY.E.MOORE@hotmail.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 /> a ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> a ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> E i i Is the system failing? <br /> ❑ it Discharge of sewage to the ground surface? <br /> ❑ i] Discharge of sewage to drain tiles or surface waters? <br /> ❑ IN 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: 3/2$/2026 <br /> (This line only can be fill and photocopied.) <br /> 12/31/2025 <br /> Original Signature: — Date: <br /> Note: Maintenance providers ust aintain accurate records of their maintenance contracts, customers, <br /> performance data,and timelines or r ewing the cart cts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071- 0(24). <br /> DEQ Annual Operation and Maintenance Report Form Rev 6.2022 <br />