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17216075— /// <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Properly Owner: <br /> DAVID YEE Phone: 541-223-1761 <br /> 12017 HOLLY LN. SE Parcel It <br /> 093W14D 00900 <br /> Site Address: <br /> City: <br /> JEFFERSON County: Marion <br /> 10-00495 Start update if 1st year in use: 5/28/2010 <br /> Permit#: <br /> System Model#: AX20 RT-1 B System serial#: 121358 <br /> Report Year: 2025 Date of Service Performed: 11/5/2025 <br /> Email Address: DLYEE6@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> El ❑ 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 /> ❑ El Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ lj Discharge of sewage to drain tiles or surface waters? <br /> D 0 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 if: *Certification 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can _• t and p (se•ied.) <br /> Date: 12/31/2025 <br /> Original Signature. ,�J� wear �� <br /> Note: Maintenance pro riders m st - main accurat. records of their maintenance contracts,customers, <br /> performance data,and •melines •r renewing the co racts, These records must be available for inspection upon <br /> request by the agency p- OAR r 171-0130(24). <br /> DEQ annual Operation and Ma lntenance Repoet Fort Rev 6/2022 <br />