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o�5-Col 514 1-1A <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> WI <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner ZACH MINTZER Phone: 503-409-5110 <br /> Site Address: 9582 70TH AVE. SE Parcel#: 092W0300900 <br /> City: TURNER county: Marion <br /> Permits: 555-21-002260-PRMT Start up date if 1st year in use: 6/22/22 <br /> AX2ORT 147555 <br /> System Models: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 1 1/21/2025 <br /> Email Address: ZMINTZER06@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ 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 /> ❑ IN Is the system failing? <br /> ❑ it Discharge of sewage to the ground surface? <br /> ❑ it Discharge of sewage to drain tiles or surface waters? <br /> ❑ in 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 583 *Certification Expiration: 3/28/2026 <br /> ('This line only can •• fil :• out and photoco•'-• <br /> 9 �.H-rt- -- <br /> Original Si natur: tI Date: 12/31/2025 <br /> Note: Maintenance providers • us t m. .in accurate records • their maintenance contracts,customers, <br /> performance data, and timeline ••r ren,wing the contracts. Th. a records must be available for inspection upon <br /> request by the agency per OAR 340-0 -0130(24). <br /> DLO Annual )peetion and Maintenance R fcn°onn i.e. 3:1n22 <br />