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• <br /> State of Oregon Department of Environmental QualityV:\ CLAI--\ ‘R <br /> rli Annual Operation and Maintenance <br /> WIN <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: JOAN & CLAY NOLEN Phone: 503-854-3790 <br /> Site Address: 49890 NORTH SANTIAM HWY SE Parcel#: 106E22AD00900 <br /> city: IDANHA County: Marion <br /> Permit#: 555-17-006901-PRMT startup date if 1st year in use: NA <br /> System Model#: PRESSURE DISTRIBUTION System Serial#: <br /> NA <br /> Report Year: 2025 Date of Service Performed: 12/10/2025 <br /> Email Address: JMNOLEN@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ 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 /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ • Is the system failing? <br /> O Q Discharge of sewage to the ground surface? <br /> O ❑� Discharge of sewage to drain tiles or surface waters? <br /> ❑ E 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{kearlycan :- fine. -n• •hot• opi- ) _ . ______________ <br /> Original Signal re: ,A LkfV Date: 12/31/2025 <br /> Note: Maintenance provide"stain accurate reco •- of their maintenance contracts, customers, <br /> performance data,and time) •- ��r renewing the contracts. ese records must be available for inspection upon <br /> request by the agency per OA- c 171-0130(24). <br /> DEC It xiaoon and '.1aintivhinne repot:=onn Rev 6,2]22 <br />