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State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner GORDON McLAUGHLIN Phone: 503-371-4643 <br /> Site Address: 23497 SANTIAM WAY SE Parcel#: 092E17AB01400 <br /> City: LYONS county: Marion <br /> Permit#: 555-17-008330-PRMT Start up date if 1st year in use: NA <br /> System Model#: PRESSURE DIST. System serial#: NA <br /> Report Year: 2025 Date of Service Performed: 11/25/2025 <br /> Email Address: LMAC11@HOTMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q El 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 /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ III Is the system failing? <br /> ❑ • Discharge of sewage to the ground surface? <br /> ❑ in 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 /> M 587 3/28/2026 <br /> `Certification#: C-•• = •n Expiration: <br /> (*This line only can e ut and photo e•.) <br /> originals Date:— - �r 12/31/2025 <br /> Note: Maintenance providers mus mai tam accurate -cords of their maintenance contracts,customers, <br /> performance data,and ti ' es r rene • e con cts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Annual Operation anC Maintenance Report Corr Rev 9'2022 <br />