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-/ State of Oregon Department of Environmental Quality / V 6 -72.3- <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: MARKANUNDI Phone: 503-510-5142 <br /> Site Address: 11116 BEAN ALLEY ROAD Parcel#: 555-08-03832 <br /> AUMSVILLE y Marion <br /> City: County: <br /> Permit#: 555-08-03832 8/13/2008 <br /> Start up date if 1st year in use: <br /> System Model#: ' 20N System Serial#: 114865 <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: MAHBANUNDI@YAHOO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ 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 /> ❑ I• Discharge of sewage to the ground surface? <br /> ❑ © Discharge of sewage to drain tiles or surface waters? <br /> ❑ i] 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 filled 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 /> DEC Annan.riperaeon and Maintenance P_u t Earn Res o2022 <br />