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-erg, State of Oregon Department of Environmental Quality 25.D11 6,71'/ y <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: MARK STULLER 503-364-5395 <br /> Phone: <br /> Site Address: 7783 JACKSON HILL RD SE 083W26C01500 <br /> Parcel#: <br /> City: SALEM Marion <br /> County: <br /> Permit#: 555-23-007123 09/1 B/2024 <br /> Startup date tf 1st year in use: <br /> System Model#: MICROFAST 037598X-23334 <br /> System Serial#: <br /> Report Year: 2025 Date of Service Performed:_9/2/2025 <br /> Email Address: MARKSTULLER@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not preftll and photocopy checkboxes) <br /> Yes No <br /> *❑ U -Was maintenance performed as required by septic system rules and the manufacturer? <br /> ❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ W Is the system failing? <br /> ❑ II Discharge of sewage to the ground surface? <br /> ❑ IN 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 /> 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#: M 587 3/28/2026 <br /> *Certification Expiration: <br /> ('This line only can be fie d pied.) <br /> Original Signature: \ ■ / Date: 12/31/2025 <br /> Note: Maintenance providers u t mai thin accu to records of their maintenance contracts, customers, <br /> performance data, and timelin s or re wing the ntracts. These records must be available for inspection upon <br /> request by the agency per OA 0-071- 0(24 <br /> DEG Annual Operation and blaintenano Repot Farr Rev ,i2022 <br />