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)7 a0 11V61 <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Propertyowner: DAVID ANDERSON Phone: 541-647-4379 <br /> 6982 RIVERBEND DR. NE O61E2OCOO17O1 <br /> Site Address: Parcel#: <br /> City: SILVERTON County: Marion <br /> Permit#: 1 O-02520 Start up date if 1st year in use: 3/3/11 <br /> System Model#: AX2ORT System Serial#: 121961 <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: djanders6O@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> L^J LI 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 /> l ❑ 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 /> ❑ 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 /> 1 certifythatthis 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 fill9e\out and pi d.) <br /> Original Signature: , Date: 12/31/2025 <br /> Note: Maintenance provide m t main n ccurate records of their maintenance contracts, customers, <br /> performance data, and timelin for renewi he contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24), <br /> DEO Annual Operation and Maintenance Report Farm Rev.6/2022 <br />