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IE-b0k5"1-1—Ti\)aq <br /> 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 JOHN MILLER Phone: 971-645-2383 <br /> Site Address: 15292 OTTAWAY RD. Parcel#: 041W130000801 <br /> City: AURORA County: Marion <br /> Permit#: 555-15-003550-SEP Stan up date if 1st year in use: 8/26/2015 <br /> System Model#: AX2ORT System Serial#: 132052 <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: BOB@MSCCANBY.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> E ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> E ❑ 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 /> ❑ 0 Is the system failing? <br /> ❑ ❑� 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 /> 'Certification#: M 587 'Certification Expiration: 3/28/2026 <br /> ('This line only can be filled out and photocopied.) <br /> —��Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers must maintain accurate records of their maintenance contracts, customers, <br /> performance data, and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> LID Ar)INI al I Jper W2Intrnanco He pril .c.. i.e:.., <br />