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a5 tDDa\ts,\- zAQR <br /> ../ 2 State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> LOUISE MYERS 503-435-8132 <br /> Property Owner Phone: <br /> Site Address: 235 BOULDER ST N Parcel#: 105E01BC09400 <br /> City: DETROIT County: Marion <br /> Permit#: `�`� 21-070797 Start up date if 1st year in use: 05/13/2024 <br /> System Model#: SEEPAGE BED System Serial#: NA <br /> Report Year: 2025 Date of Service Performed: 12/18/2025 <br /> Email Address: LOUISEMYERS@frontier.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> O ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] 0 Is the system operating in accordance with the agent-approved design specifications? <br /> El El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ It Is the system failing? <br /> ❑ IN Discharge of sewage to the ground surface? <br /> ❑ It Discharge of sewage to drain tiles or surface waters? <br /> ❑ It 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 fill- • t and ph.,•copied. <br /> r - 12/31/2025 <br /> Original Signature_ — aSA —At Date: <br /> Note: Maintenance providers ust .intain accura - -••rds of their maintenance contracts, customers, <br /> performance data, and timeline for r-newing the contra .-. These records must be available for inspection upon <br /> request by the agency per OAR r • 1-0130(24). <br /> DEC)Annual Operation and Maintenance Report Form Rev 6:'2022 <br />