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State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property owner: MICHAEL MYERS Phone: 503-437-7019 <br /> Site Address: 215 MAIN ST Parcel#: 061 W 1 OBA11100 <br /> IDANHA Marion <br /> City: County: <br /> 555-23-009891-PRMT 11/27/24 <br /> Permit#: Startup date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 12/10/2025 <br /> Email Address: MICHAELSBRAU@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> -❑ -❑ 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 /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ 111 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): Cory Morgan - A & B Septic Service <br /> *Certification#: M 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can b- - •• out an. •au• er. ed' <br /> Original Signatu - I _ a' Date: 12/31/2025 <br /> Note: Maintenance provi,ers mu-t maintai -ccurate -cords of their maintenance contracts, customers, <br /> performance data,and ti -lines Ur renewing •e cont acts. These records must be available for inspection upon <br /> request by the agency per 0 : 3,0-071-0130(24 . <br /> DEC Ainual:r -atonEnr.DainFonaoFe Pop ;rFo"•' Hev .2022 <br />