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,22- 0o1251 - i' 1 <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> rilll <br /> DEQ Report Form <br /> DEQ <br /> General Information (Complete ALL information) <br /> Property Owner: TONY SVAY Phone: 971-701-4645 <br /> Site Address: 1037 MEADOWS LN. SE. Parcel#: 093W15B000201 <br /> City: JEFFERSON County: Marion <br /> Permit#: 555-20-009296 Start up date if 1st year in use: 6/17/21 <br /> System Model#: AX2ORT System Serial#: 145431 <br /> Report Year: 2025 Date of Service Performed: 12/04/2025 <br /> Email Address: SVAYT20@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 /> El ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> • ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ El Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> cer-tfythattfiisreport 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 587 'Certification Expiration: 3/28/2026 <br /> ('This line only ca -• out and •�copied.) <br /> 4'pp/ y ___ -.� 12/31/2025 <br /> Original Signature: di/ // idexii Date: <br /> Note: Maintenance provider- m - maintain ac urate recor it intenance contracts,customers, <br /> performance data,and timeline fo renewing e contracts. These records must be available for inspection upon <br /> request by the agency per S - - 340-i 1-013r(24). <br /> DEO Annual Operatron and Maintenance Report Form Rev.6/2022 <br />