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zz-*)/9.3'F- jay <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> JAN VARNEY 906-361-3005 <br /> Property Owner: Phone: <br /> Site Address: 14841 CANYON VIEW LN. Parcel#: 071 W120000603 <br /> City: SILVERTON county: Marion <br /> Permit#: 555-19-007610-PRMT Startupdate if 1st year in use: 5/14/21 <br /> System Model#: AX2ORT System Serial#: 144117 <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: Yooperjan@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> O ❑ 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 /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> LI i] Discharge of sewage to drain tiles or surface waters? <br /> ❑ I] 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 7 *Certification Expiration: 3/28/2026 <br /> (*This line only can be ill out and •.• ocopied.) <br /> -- 12/31/2025 <br /> Original Signature: A r��j%4I�y�� Date: <br /> err' I • . <br /> Note: Maintenance providers ust maint-'n accurate records of their maintenance contracts,customers, <br /> performance data, and timeli for rene 'ng the contracts. These records must be available for inspection upon <br /> request by the agency per •-R •. 0-071-0 30(24). <br /> DEG Annual opA+a,on arid 4,1aintenance Rey:, , 1, Nov ;21)?2 <br />