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k$-to\518 7 a? <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> ria <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Curtis Myrick & William Allen Phone: 503-931-7178 <br /> Site Address: 7881 Terrance Lane SE parcel#: 082W26D 02400 <br /> City: Aumsville coup Marion <br /> Y <br /> 07-06266 Start up date if 1st year in use: <br /> Permit#: NA <br /> System Model#: AX20-1 B System Serial#: 113350 <br /> Report Year: 2025 Date of Service Performed: 10/22/2025 <br /> Email Address: BAGLEYDUO@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> u- 17,u 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 /> x❑ 0 Is the system currently under a service contract with a certified maintenance provider? <br /> O MI Is the system failing? <br /> 0 • Discharge of sewage to the ground surface? <br /> ❑ NI 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 be ed gut and hoto pied) <br /> Original Signal re: Date: 12/31/2025 <br /> Note: Maintenance • e-" <br /> rs m t maintain a u to records of their ntenance contracts,customers, <br /> performance data,and tim nes renewing th ntracts. T ecords must be available for inspection upon <br /> request by the agency per 0 40-071-0130(24 . <br /> DEG Annual Operation and Maintenance Report Fona Rev 612022 <br />