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State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> Pia <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: JARYN MONTGOMERY Phone: 503-510-9003 <br /> Site Address: 10175 SUNNYSIDE RD. Parcel#: 093W10A00200 <br /> City: JEFFERSON County: Marion <br /> Permit#: 555-20-001001 Start up date if 1 st year in use: 6/25/2020 <br /> System Model#: AX20RT UV System Serial#: 141573 <br /> Report Year: 2025 Date of Service Performed: 10/29/2025 <br /> Email Address: JARYN@MCGCORP.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ ❑� Was maintenance performed as required by septic system rules and the manufacturer? <br /> ❑ El 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 /> ❑ ® Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ • 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 /> *Certification#: M 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can be • :ut and photocopied.) <br /> Original signatur. ,,, .. I,�j%L_ Date: 12/31/2025 <br /> r <br /> Note: Maintenance provide s st maintai of their maintenance contracts,customers, <br /> performance data,and time',e- for renewing the co - . These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Annual Operation and Maintenance Repair Farm- Rev 6r2022 <br />