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,-,-r-q. State of Oregon Department of Environmental Quality /U 1 D/1P 7 744 y <br /> Sal Annual Operation and Maintenance <br /> rill <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner: LINDA LOUGEE 971-301-3538 <br /> Phone: <br /> Site Address: 12127 HUMMINGBIRD LN. SE 093W23B00301 <br /> Parcel#: <br /> City: JEFFERSON Marion <br /> County: <br /> Permit#: 555-17-00343 10/8/17 <br /> Startup date if 1st year in use: <br /> #: AX2ORT 136022 System Model <br /> System Serial#: <br /> Report Year: 2025 9/17/2025 <br /> Date of Service Performed: <br /> Email Address: pol831ou@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> O 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q 0 Is the system operating in accordance with the agent-approved design specifications? <br /> I] 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ El Is the system failing? <br /> ❑ In Discharge of sewage to the ground surface? <br /> ❑ Ill 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 bg.fisetlyatand pho pied) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers us aintain accu to records of their maintenance contracts, customers, <br /> performance data, and timelines for re wing the ntracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0T3 4 <br /> DEO Annual Operation and Maintenance.Reoao For Rev 6.2022 <br />