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026( W545= 4/ <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner: SETH & KAITLYN MACK Phone: 503-930-1819' <br /> 12433 SUMMIT LOOP Parcel#: <br /> 092W20D01001 <br /> Site Address: <br /> City. TURNER County: Marion <br /> 555-18-008572-PRMT Start up date if 1st year in use: 9/13/19 <br /> Permit#: <br /> System Model#: <br /> AX2ORT System Serial#: 148183 <br /> Report Year: <br /> 2025 Date of Service Performed: 11/21/2025 <br /> Email Address: SKMACK22@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 /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> ❑ NI Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ El 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 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 Exriration: 3/28/2026 <br /> ('This line onlycanbe filled ouFand photocopied. <br /> (/ � 12/31/2025 <br /> Original Signature: L/") —) Date: <br /> Note: Maintenance providers must al in accurate re maintenance contracts, customers, <br /> performance data,and timelines for ren wing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual Operation and Malnte ranee Depart ronn Rev.62022 <br />