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State of Oregon Department of Environmental Quality ' �/ 2-MO <br /> �31 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: AKATY TORAN Phone: 503-981-9205 <br /> Site Address: 16988 ARNEY RD. Parcel#: 052W01 D00500 <br /> City. WOODBURN county: Marion <br /> Permit#: 555-20-000197 Start up date if 1st year in use: 3/15/21 <br /> System Model#: AX2ORT System Serial#: 143431 <br /> Report Year: 2025 Date of Service Performed: 10/24/2025 <br /> Email Address: akatytoran@yahoo.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> i] ❑ 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 /> ❑ it Is the system failing? <br /> ❑ it 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 /> M 87 3/28/2026 <br /> *Certification#: "Certification Expiration: <br /> (*This line only can be fit ut and p • iedJ <br /> Original Signature: ,� � Date: 12/31/2025 <br /> r . <br /> Note: Maintenance providers must a tarn a• rate reco •s of their maintenance contracts, customers, <br /> performance data, and timelines for en- ,ing the ontracts These records must be available for inspection upon <br /> request by the agency per OAR 340 r71-0 • 24) <br /> DEC Anneal Operation any Olarntenar cc kernel Form Rev 6'2022 <br />