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11- DO 79D- /N <br /> State of Oregon Department of Environmental Quality <br /> �31 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: ANDREW WEBB Phone: 971-239-8627 <br /> Site Address: 15932 Stormy Lane NE Parcel it: 071E06D002100 <br /> city: Silverton County: Marion <br /> Permit#: 05-09273 Start up date if 1st year in use: NA <br /> AX20-1 B 105504 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 4/15/2025 <br /> Email Address. kwebb.6870@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> l ❑ 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 /> LI ❑� Is the system failing? <br /> ❑ It Discharge of sewage to the ground surface? <br /> ❑ ® 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 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can b II out and p ied. <br /> Original Signature Date: 1 Z/31/2025 <br /> Note: Maintenance providers must intain accurat records of their maintenance contracts,customers, <br /> performance data, and timelin for r ewing the con racts. These records must be available for inspection upon <br /> request by the agency per OAR 340-07 130(24). <br /> DEG Annual Operation arm Maintenance Report Form Rev.6/2022 <br />