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State of Oregon Department of Environmental Quality 25 (tom- !Ay <br /> Annual Operation and Maintenance <br /> will <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Tim Bailey Phone: 503-698-8015 <br /> Site Address; 15451 Quail Rd NE Parcel#: 071 W01A00800 <br /> Silverton Marion <br /> City: County: <br /> Permit#: 555-18-004423-PRMT Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 139098 <br /> Report Year: 2025 Date of Service Performed: 3/14/2025 <br /> Email Address: GLIDIN2014@GMAIL.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 /> x❑ 0 Is the system operating in accordance with the agent-approved design specifications? <br /> l] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ It Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ It Discharge of sewage to drain tiles or surface waters? <br /> ❑ It 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: 3/28/26 <br /> ('This line only can be B�out/a and photoc ied.) <br /> Original Signature: cvt T Date: 12/31/2025 <br /> Note: Maintenance providers\,iust maintain a rate 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 /> )F rricrIIC i .,�.rer,aLc on-�� .e. O22 <br />