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i1--- OOo1i4— ia6Z <br /> ./ t State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> rill <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: CARLY TAYLOR Phone: 593-930-1066 <br /> s eAddess: 455 CLESTER ST. Parcel 105E02AD09400 <br /> City: DETROIT county: Marion <br /> Permit#: 12-03882 Start up date if 1st year in use: 5/23/13 <br /> System Model itAX20N-1 A System Serial#: 131442 <br /> Report Year: 2025 Date of Service Performed: 10/17/2025 <br /> Email Address: CARLYSUETAYLOR@ICLOUD.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> lI 0 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 /> El 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ . Discharge of sewage to the ground surface? <br /> ❑ M Discharge of sewage to drain tiles or surface waters? <br /> El ❑� 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 /> *Certifcatilor #: M 587 *Certification Expiration: 3/28/2026 <br /> Pr <br /> ('This line only can be A out andph•toco•ied.) <br /> wi.� Date: 12/31/2025 <br /> Original Signature: <br /> Note: Maintenance provide 7 must mai -in accurate - ... o heir maintenance contracts, customers, <br /> performance data,and ti e -s for ren wing the contracts. These records must be available for inspection upon <br /> request by the agency per OA- 40-07 -0130(24). <br />