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—DD91o5�-/N <br /> ,ram 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: ANNE-MARIE STORMS Phone: 503-559-3451 <br /> s eAddress: 8983 WEST STAYTON RD. parcel#: 092W01B000100 <br /> City: AUMSVILLE county: Marion <br /> Permit#: 555-24-002184-PRMT 12/19/2024 <br /> Start up date if 1st year in use: <br /> System Model#: AX2ORT UV System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 7/28/2025 <br /> Email Address: AM_STORMS@HOTMAIL.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 /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ IN Discharge of sewage to the ground surface? <br /> ❑ 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 /> 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#: M 587 'Certification Expiration: 3/28/2026 <br /> ('This line only can be/ 1 l elf outand h pied.) <br /> Original Signature: (J Date: 12/31/2025 <br /> Note: Maintenance providers ust aintain accurate records of their maintenance contracts, customers, <br /> performance data,and timelin s for ewinc the contracts. These records must be available for inspection upon <br /> request by the agency per O 340-071- -0(24). <br /> DEO Annual Opetatior and Ma int, acre Report Form 4ev.G2022 <br />