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-t \t T t <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL Information) <br /> JOANNE NATHAN 503-871-8868 <br /> Property Owner: Phone: <br /> 25657 TAYLOR PARK RD. 092E10DC00700 <br /> Site Address: Parcel#: <br /> City: LYONS county: Marion <br /> 13-03379 Start up yearuse:date if 1st in <br /> Permit#: NA <br /> System Model#: AX20N System Serial#: 146433 <br /> Report Year: 2025 Date of Service Performed: 3/4/2025 <br /> Email Address: JOMAMA05.JN@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 /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ 0 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 /> 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 b Iled ouq and p opied.) <br /> Original Signature: ,�( / Date: <br /> 12/31/2025 <br /> Note: Maintenance providers m ain in accur:to records of their maintenance contracts, customers, <br /> performance data, and timelines for rene ing the c• tracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0 - 4). <br /> DF:]Arrtual eneuat.an a. 1.1aulrealdrae Repo 1= F Pev @ 2022 <br />