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State of Oregon Department of Environmental Quality ^0b37g- /' • & y <br /> Annual Operation and Maintenance <br /> pQ, Report Form <br /> General Information (Complete ALL information) <br /> Property owner, ROBERT & KATHRYN BARNES Phone: 503-743-2326 <br /> Site Address: 205 S PATTON RD Parcel#: 105E01 CB09200 <br /> City. DETROIT County: Marion <br /> Permit#: 555-24-004799-PRMT-01 Start up date if 1st year in use: 10/14/2024 <br /> System Model#: AX2ORT System Serial#: MVP <br /> Re ortYear: 2025 12/31/2025 <br /> P Date of Service Performed.. <br /> Email Address: UNKNOWN <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 /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> 0 ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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 fined out and photocopied.) <br /> Original Signature: ��� - Date: 12/31/2025 <br /> Note: Maintenance providers must maintain accurate records of their maintenance contracts, customers, <br /> performance data, and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> IJEQ Annual rie. ann MaritQnanoe Y_{on F or Re 62✓2 <br />