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State of Oregon Department of Environmental Quality a-3!/63/ t " /'• / <br /> SA Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner: KANDACE KIBLER 503-931-6883 <br /> Phone: <br /> Site Address: 14126 CREEKSIDE WAY 092W33B00200 <br /> Parcel#: <br /> City: TURNER Marion <br /> County: <br /> Permit#: 09-08023 11/21/18 <br /> Start up date if 1st year in use: <br /> it 139090 System Model <br /> System Serial#: <br /> Report Year: 2025 10/8/2025 <br /> Date of Service Performed: <br /> Email Address: KLKIBLER31@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q 0 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ © Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ e Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> 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 bah! .. •ut and photoco•i-•.) <br /> Original Signature: r amitd A Date: 12/31/2025 <br /> Note: Maintenance provi•ers must ainta accurat= records of their maintenance contracts,customers, <br /> performance data,and tim• ' - renewin• • - • tracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual Operation and Maintenanon Report Form Rev.612022 <br />