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-/-`4T- State of Oregon Department of Environmental Quality /7 4)10039 /iV <br /> �3t Annual Operation and Maintenance <br /> via <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: ALLISON MARLEY Phone: 503-371-3696 <br /> Site Address: 5418 BALLYNTINE CREEK LN. Parcel# 083W17B01400 <br /> City. County:county: Marion <br /> 555-15-001684-SEP Start up date iflstyearinuse: NA <br /> Permit#: <br /> System Model#: AX2ORT System Serial#: 132995 <br /> Report Year: 2025 Date of Service Performed: 10/27/2025 <br /> Email Address: chrisandallisonmarley@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 /> I] ❑ 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 /> ❑ ® Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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 ' _• out and ph• :.•• '-•J <br /> 12/31/2025 <br /> Original Signatures --r .4 Date: <br /> Note: Maintenance providers ust ai .in accurate reco*s of their maintenance contracts, customers, <br /> performance data, and timelin- • rene ' • the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-013r - <br /> DEO Annual Operation and Maintenance Report Form Rev 612022 <br />