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State of Oregon Department of Environmental Quality a -wa\L( l---16a9 <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: PATTY NOICE Phone: 503-391-2648 <br /> Site Address: 120 N. SANTIAM HWY E. Parcel#: 093E27DA01900 <br /> City: GATES County: Marion <br /> Permit#: 555-21-008421-PRMT Start up date if 1 st year in use: 3/4/24 <br /> System Model#: PRESSURE DISTRIBUTION System Serial#: N/A <br /> Report Year: 2025 Date of Service Performed: 10/30/2025 <br /> Email Address: NOICEPATTY@YAHOO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> a ❑ 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❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> El • Is the system failing? <br /> El • Discharge of sewage to the ground surface? <br /> ❑ ❑� Discharge of sewage to drain tiles or surface waters? <br /> El ❑� 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 /> M 587 3/28/2026 <br /> 'Certification#: 'Certification Expiration: <br /> ('This line only can filled our and ••• •-:.:: <br /> r� —� 12/31/2025 <br /> Original Signatu e: t Date: <br /> Note: Maintenance prov'•ers mu.t maintain acc to records of eir maintenance contracts, customers, <br /> performance data, and ti •-lines 'a renewing the c racts. The— records must be available for inspection upon <br /> request by the agency per • • • -0-071-0130(24). <br /> DEC)Annual Operation and Maintenance Report Furls Rev.612022 <br />