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9J� <br /> „erg,, State of Oregon Department of Environmental Quality �.2— 00,2 -may <br /> ►��3_! Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: RAFAEL & IRENE VILLA Phone: 541-731-5061 <br /> Site Address: 21845 FERRY ST SE. Parcel#: 092E18BCO2600 <br /> City: STAYTON County: Marion <br /> Permit#: 555-20-006840- PRMT Start up date if 1 st year in use: 10/18/2021 <br /> System Model#: AX2ORT System Serial#: 146229 <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: RAFAEL.IRENE.V@GMAIL.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 /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ MI Is the system failing? <br /> ❑ • Discharge of sewage to the ground surface? <br /> ❑ It Discharge of sewage to drain tiles or surface waters? <br /> ❑ It Sewage backup into plumbing fixtures? <br /> If you answered"Yes'on the last four questions,was a repair permit obtained? If not,explain: <br /> 1-certify-Drat-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 be filled out and photocopied.) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers must maintain accurate records of their maintenance contracts, customers, <br /> performance data,and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> OF.0 Annual operation 3ntl Li :r tenanue Repon Fans Rev LA2:122 <br />