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22- m/Pio-A y <br /> ,.-reY_. 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: KRISTIE WILLIAMS Phone: 503-577-9395 <br /> Site Address: 14915 QUALL RD. Parcel#: 071 W01 C01000 <br /> SILVERTON Marion <br /> City: County: <br /> 555-21-000355-PRMT 5/17/21 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System serial#: 145054 <br /> Report Year: 2025 Date of Service Performed: 6/13/2025 <br /> Email Address: KRISTIEMAREN@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> --j LI Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ 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 /> ❑ Q Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ I] Discharge of sewage to drain tiles or surface waters? <br /> ❑ 111 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 bjfill out nd photo --•)_ _ <br /> Original Signature: `3u� Date: 12/31/2025 <br /> Note: Maintenance providers must aintain ccurate re, •rds of their maintenance contracts,customers, <br /> performance data,and timeli s fo renewing .•e contra s. These records must be available for inspection upon <br /> request by the agency per OA -071-0130(2 . <br /> 2FO An m al Operation and reennenance Report Fern key.62C22 <br />