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State of Oregon Department of Environmental Quality /67 1)/5/2 41 t/ <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: MATT LEIMBACH Phone: 503-999-8778 <br /> Site Address: 6733 KEENE RD. NE Parcel#: 052W2700700 <br /> City: GERVAIS county: Marion <br /> Permit#. 555-15-006035-SEP Start up date if 1st year in use: NA <br /> System Model Al AX2ORT System Serial#: 132626 <br /> Report Year: 2025 Date of Service Performed: 9/22/2025 <br /> Email Address: mbleimbach@hotmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> a 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 /> O ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ no Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ ® 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 /> 1.certify-that+his 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 it: *Certification 587 "Certification Expiration: 3/28/2026 <br /> ('This line only can filled)out and ph pied <br /> Original signature: �v� - Date: 12/31/2025 <br /> Note: Maintenance providers m st maintain a ate records of their maintenance contracts, customers, <br /> performance data,and timelin or renewing the contracts. 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 Report Force Rev.612022 <br />