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I/ - DOd CRC/ <br /> ./' State of Oregon Department of Environmental Quality <br /> S4 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: WILLIAM & MARIBETH TAENNLER Phone: 503-678-2315 <br /> Site Address: 9654 IDA LN. Parcel#: 041 W 19BO17O1 <br /> City: County:county: Marion <br /> Permit#: 07-01755 Start up date if 1st year in use: 9/9/14 <br /> System Model#: AX2ORT 1 B System Serial#: 129128 <br /> Report Year: 2025 Date of Service Performed: 6/17/2025 <br /> Email Address: WTAENNLER@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> -IJ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> O ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ III 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 /> *Certification#: 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can be fill u .hhh. •led.) <br /> Original Signature: fit <br /> (i# p Date: 12/31/2025 <br /> Note: Maintenance providers. � t maintai accurate records of their maintenance contracts, customers, <br /> performance data,and timelines fo renewi t the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340.4 1-0 30(24). <br /> DEC Annual Operation and Maintenance Report Form Rev.E,'2022 <br />