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60 0114- NQ <br /> _erg. State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: DAMON SUMP Phone: 503-476-6842 <br /> Site Address: 4265 N LUCIER AVE. NE Parcel#: 042W19AD04600 <br /> ST. PAUL Marion <br /> City: County: <br /> Permit#: 555-13-005769 Start up date if 1 st year in use: 9/10/2014 <br /> System Model#: AX2ORT System Serial#: 129125 <br /> Report Year: 2025 Date of Service Performed: 7/21/2025 <br /> Email Address: DAMONSUMP@MSN.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 /> El El Is the system operating in accordance with the agent-approved design specifications? <br /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ II Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ II 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#: M1l587 *Certification Expiration: 3/28/2026 <br /> (*This line only can be 4I1e1 out an• • ied <br /> �l III' <br /> Original Signature: �_ Date: 12/31/2025 <br /> Note: Maintenance providers mu main!:in accura - records of their maintenance contracts,customers, <br /> performance data, and timelines r rene 'ng the co'tracts. These records must be available for inspection upon <br /> request by the agency per OAR li r-071-r 130(24). <br /> DEC Annua!Operation and Maintenance Report Form Rev 6;2022 <br />