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„e State of Oregon Department of Environmental Quality /7— ODD 7 3& l//1/ <br /> vili Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: SARAH LEY Phone: 503-941-6391 <br /> Site Address: 9209 Champoeg Rd Parcel#: 042W01 D00200 <br /> Cit : Aurora County: Marion <br /> Y <br /> Permit#: 09-05292 Start up date if 1st year in use: NA <br /> System Model#: AX2O-1 A System Serial#: 123719 <br /> Report Year: 2025 Date of Service Performed: 6/17/2025 <br /> Email Address: SARAH.M.LEY85@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❑ 0 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 /> ❑ III Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ in Discharge of sewage to drain tiles or surface waters? <br /> ❑ It 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 o etl1_ <br /> Original Signature: Epp Date: <br /> 12/31/2025 <br /> Note: Maintenance providers us ma lain accura - records of their maintenance contracts,customers, <br /> performance data, and timelines r rene. ; • the co tracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0131 • . <br /> DEQ Annual operation and Maintenance Report Fovr Rev 612022 <br />