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2z-ed/ 71- /4Y 5 <br /> ./`r:,_ 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: MIKE & DIANA WRIGHT Phone: 503-949-1613 <br /> 14951 CANYON VIEW LN. Parcel#: 071W120000601 <br /> Site Address: <br /> City: SILVERTON County: Marion <br /> Permit#: 555-19-008406 Start up date if 1st year in use: 2/18/20 <br /> System Modelt AX2ORT system serial#: 141501 <br /> Report Year: 2025 Date of Service Performed: 4/15/2025 <br /> Email Address: mikelwright@hotmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ 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 /> I] ❑ 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 /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ ® 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 : •Certification Expiration: 3'28'2026 <br /> (*This line only can be lied o - , (I•.•c••i--) <br /> Original Signature: �� 1 /� Date: <br /> 12/31/2025 <br /> Note: Maintenance provider- mai ain acc ate records of their maintenance contracts,customers, <br /> performance data,and timel •- re wing the ontracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-0 -0130(24.. <br /> DEQ mutual operation and Maintenance Report Form Re. o':2D28 <br />